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Cureus May 2024Background Abdominal wound dehiscence, a serious postoperative issue, remains a significant concern for surgeons due to its potential to increase patient mortality and...
Background Abdominal wound dehiscence, a serious postoperative issue, remains a significant concern for surgeons due to its potential to increase patient mortality and morbidity. Disruption can occur at any point after surgery, sparking debate over the optimal closure method for midline vertical abdominal wounds. Therefore, it's crucial to determine the safest approach. Our randomized clinical trial is planned to compare the risk of a burst abdomen associated with the Hughes abdominal closure technique to that of continuous abdominal closure. Methods All patients >18 years scheduled for emergency midline laparotomy were randomly assigned into two groups using computer-generated random numbers: Group A underwent Hughes repair (12 patients) and Group B underwent continuous closure (17 patients). Preoperative data, including patient demographics, and postoperative outcomes, such as time for rectus closure, wound dehiscence, surgical site infection (SSI), and length of hospital stay, were documented for analysis. Results The study found that the average patient age was 37.89 years, with more males than females. Both groups had an equal distribution of co-morbidities (p = 0.468), but none of these factors were statistically significant. Burst abdomen occurred in 25% of group A and 41.1% of group B (p = 0.367, not significant). Incisional hernia was absent in both groups. Surgical site infection (p = 0.119) and respiratory complications (p = 0.16) were not statistically significant between groups. However, in group A, the regressive analysis showed significant associations between burst abdomen, surgical site infection (p = 0.018), and respiratory complications (p = 0.007), while in group B, these associations were not significant (p = 0.252 for SSI and p = 0.906 for respiratory complications). Conclusion The occurrence of burst abdomen and closure time differences between continuous and Hughes techniques were not significant. The Hughes technique was quicker to learn (32 vs. 22 minutes). Burst abdomen was more common in continuous closure (group A: 25% vs. group B: 41%), favoring the Hughes technique. Factors like age, gender, and others didn't significantly impact the burst abdomen in either group.
PubMed: 38910747
DOI: 10.7759/cureus.60816 -
Cureus May 2024Hip bipolar hemiarthroplasty, a widely employed surgical intervention for managing hip fractures and degenerative hip diseases, can pose significant challenges when...
Hip bipolar hemiarthroplasty, a widely employed surgical intervention for managing hip fractures and degenerative hip diseases, can pose significant challenges when revisions become necessary due to complications such as implant loosening, instability, or breakage. This case report presents the intricate management of a 58-year-old male who presented with worsening left hip pain a decade after undergoing hip replacement surgery. Despite a thorough preoperative assessment ruling out infection, intraoperative complexities included the necessity for extended trochanteric osteotomy (ETO) to address a broken stem and associated metallosis. Successful revision surgery was meticulously executed, incorporating techniques for implant removal, femoral shaft augmentation, and postoperative rehabilitation. The ensuing discussion explores the multifaceted aspects of failed hemiarthroplasty, emphasizing the critical roles of surgical precision, judicious patient selection, and ongoing research endeavors aimed at refining surgical strategies to optimize patient outcomes. This case underscores the imperative of a multidisciplinary approach and the continued imperative for advancements in surgical methodologies for effectively managing revision hip arthroplasty cases, thus enhancing the quality of patient care in this intricate clinical domain.
PubMed: 38910740
DOI: 10.7759/cureus.60948 -
Cureus May 2024Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the...
Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the postoperative anatomical changes in AMAB individuals who underwent GAS using magnetic resonance imaging (MRI) and to compare it with cis-females, thereby assessing the efficacy of the surgical technique in achieving pelvic anatomy similar to cis-females. Methodology This was a prospective observational study done in a tertiary care hospital. AMAB individuals who underwent gender affirmation genital surgery using single-stage solely penile skin inversion vaginoplasty were included after informed consent and approval by the Institutional Human Ethics Committee. Patients with complications such as deep space surgical site infection (SSI) and neo-vaginal prolapse were excluded. All the study participants were advised a vaginal self-dilatation regimen, reviewed three months after the surgery, and subjected to an MRI of the pelvis with a vaginal tutor. Parameters such as neo-vaginal depth, alpha (α) angle, rectovaginal thickness, and remnant of corpora cavernosa were measured and compared with cis-female parameters measured from images in the archives from the Department of Radiology. Result A total of 21 patients were included in the study, with a mean age of 27±4.7. Between the study group and cis-females, no significant difference was seen in vaginal depth, and cis-females had significantly higher values in other parameters. There was a significant difference between the subgroups, i.e., defaulters and non-defaulters in soft tissue parameters such as vaginal depth (p=0.001), α angle (p=0.002), and rectovaginal thickness (p=0.002) with the non-defaulter patients having higher values. Conclusion Single-stage penile skin inversion vaginoplasty is capable of producing anatomical parameters, importantly neo-vaginal depth, which is fairly comparable with cis-female, as evident in the non-defaulter subgroup patients. Proper compliance with the vaginal dilatation regimen plays a significant role in the maintenance of soft tissue pelvic anatomical parameters.
PubMed: 38910612
DOI: 10.7759/cureus.60823 -
Bone & Joint Open Jun 2024In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and...
AIMS
In metal-on-metal (MoM) hip arthroplasties and resurfacings, mechanically induced corrosion can lead to elevated serum metal ions, a local inflammatory response, and formation of pseudotumours, ultimately requiring revision. The size and diametral clearance of anatomical (ADM) and modular (MDM) dual-mobility polyethylene bearings match those of Birmingham hip MoM components. If the acetabular component is satisfactorily positioned, well integrated into the bone, and has no surface damage, this presents the opportunity for revision with exchange of the metal head for ADM/MDM polyethylene bearings without removal of the acetabular component.
METHODS
Between 2012 and 2020, across two centres, 94 patients underwent revision of Birmingham MoM hip arthroplasties or resurfacings. Mean age was 65.5 years (33 to 87). In 53 patients (56.4%), the acetabular component was retained and dual-mobility bearings were used (DM); in 41 (43.6%) the acetabulum was revised (AR). Patients underwent follow-up of minimum two-years (mean 4.6 (2.1 to 8.5) years).
RESULTS
In the DM group, two (3.8%) patients underwent further surgery: one (1.9%) for dislocation and one (1.9%) for infection. In the AR group, four (9.8%) underwent further procedures: two (4.9%) for loosening of the acetabular component and two (4.9%) following dislocations. There were no other dislocations in either group. In the DM group, operating time (68.4 vs 101.5 mins, p < 0.001), postoperative drop in haemoglobin (16.6 vs 27.8 g/L, p < 0.001), and length of stay (1.8 vs 2.4 days, p < 0.001) were significantly lower. There was a significant reduction in serum metal ions postoperatively in both groups (p < 0.001), although there was no difference between groups for this reduction (p = 0.674 (cobalt); p = 0.186 (chromium)).
CONCLUSION
In selected patients with Birmingham MoM hips, where the acetabular component is well-fixed and in a satisfactory position with no surface damage, the metal head can be exchanged for polyethylene ADM/MDM bearings with retention of the acetabular prosthesis. This presents significant benefits, with a shorter procedure and a lower risk of complications.
PubMed: 38910515
DOI: 10.1302/2633-1462.56.BJO-2023-0165.R1 -
BMJ Open Jun 2024Biological disease-modifying antirheumatic drugs (bDMARDs) have revolutionised the treatment of inflammatory arthritis (IA). However, many people with IA still require...
PERI-operative biologic DMARD management: Stoppage or COntinuation during orthoPaEdic operations (the PERISCOPE trial) - a study protocol for a pragmatic, UK multicentre, superiority randomised controlled trial with an internal pilot, economic evaluation and nested qualitative study.
INTRODUCTION
Biological disease-modifying antirheumatic drugs (bDMARDs) have revolutionised the treatment of inflammatory arthritis (IA). However, many people with IA still require planned orthopaedic surgery to reduce pain and improve function. Currently, bDMARDs are withheld during the perioperative period due to potential infection risk. However, this predisposes patients to IA flares and loss of disease control. The question of whether to stop or continue bDMARDs in the perioperative period has not been adequately addressed in a randomised controlled trial (RCT).
METHODS AND ANALYSIS
PERISCOPE is a multicentre, superiority, pragmatic RCT investigating the stoppage or continuation of bDMARDs. Participants will be assigned 1:1 to either stop or continue their bDMARDs during the perioperative period. We aim to recruit 394 adult participants with IA. Potential participants will be identified in secondary care hospitals in the UK, screened by a delegated clinician. If eligible and consenting, baseline data will be collected and randomisation completed. The primary outcome will be the self-reported PROMIS-29 (Patient Reported Outcome Measurement Information System) over the first 12 weeks postsurgery. Secondary outcome measures are as follows: PROMIS - Health Assessment Questionnaire (PROMIS-HAQ), EQ-5D-5L, Disease activity: generic global Numeric Rating Scale (patient and clinician), Self-Administered Patient Satisfaction scale, Health care resource use and costs, Medication use, Surgical site infection, delayed wound healing, Adverse events (including systemic infections) and disease-specific outcomes (according to IA diagnosis). The costs associated with stopping and continuing bDMARDs will be assessed. A qualitative study will explore the patients' and clinicians' acceptability and experience of continuation/stoppage of bDMARDs in the perioperative period and the impact postoperatively.
ETHICS AND DISSEMINATION
Ethical approval for this study was received from the West of Scotland Research Ethics Committee on 25 April 2023 (REC Ref: 23/WS/0049). The findings from PERISCOPE will be submitted to peer-reviewed journals and feed directly into practice guidelines for the use of bDMARDs in the perioperative period.
TRIAL REGISTRATION NUMBER
ISRCTN17691638.
Topics: Humans; Orthopedic Procedures; United Kingdom; Antirheumatic Agents; Pragmatic Clinical Trials as Topic; Perioperative Care; Qualitative Research; Multicenter Studies as Topic; Pilot Projects; Cost-Benefit Analysis; Biological Products
PubMed: 38910007
DOI: 10.1136/bmjopen-2024-084997 -
The Journal of Arthroplasty Jun 2024This study reports the minimum 10 year results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH)...
AIMS
This study reports the minimum 10 year results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing.
METHODS
Of the 276 THAs included in this study, 237 (85%) were available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. There were eleven deaths that occurred during the follow-up. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up.
RESULTS
After a minimum of 10 years, implant survivorship was 98.7%. There were three revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles (UCLA) activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. In the 10 years following implantation, at least 43% of patients reported hearing a squeaking noise from the prosthesis. All patients who had squeaking hips were satisfied with the surgery. The mean titanium level was 2.2 μg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation.
CONCLUSION
A LDH CoC THA provides outstanding long-term (minimum 10 year) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.
PubMed: 38909852
DOI: 10.1016/j.arth.2024.06.045 -
International Journal of Surgery Case... Jun 2024Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, with jejunal GISTs being particularly uncommon. Jejunal GISTs causing perforation and acute diffuse...
INTRODUCTION
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, with jejunal GISTs being particularly uncommon. Jejunal GISTs causing perforation and acute diffuse peritonitis is rare.
CASE PRESENTATION
A 53-year-old female with a history of hypertension presented with severe, acute abdominal pain and vomiting. Examination revealed abdominal distension, tenderness, and guarding, with imaging suggestive of gastrointestinal perforation. Emergency laparotomy revealed a 9 cm × 8 cm mass with perforation in the jejunum, which was resected which on histopathological examination confirmed a low-grade GIST. The postoperative course was complicated by a wound infection, managed with antibiotics and secondary suturing. At one-year follow-up, the patient remained disease-free without the need for adjuvant therapy.
CLINICAL DISCUSSION
The most common symptoms of jejunal GISTs include vague abdominal pain or discomfort, early satiety, obstruction or hemorrhage. Preoperative diagnosis and confirmation of GIST is difficult due to nonspecific symptoms and none of the radiographic procedures can establish the diagnosis with certainty. The surgical excision of the tumor along with infiltrated tissues is the treatment of choice for GIST.
CONCLUSION
This case underscores the necessity of considering GISTs in differential diagnoses of acute abdomen and the critical role of prompt surgical management and multidisciplinary care in achieving favorable outcomes.
PubMed: 38908159
DOI: 10.1016/j.ijscr.2024.109922 -
The Lancet. Digital Health Jul 2024Pulmonary complications are the most common cause of death after surgery. This study aimed to derive and externally validate a novel prognostic model that can be used...
A prognostic model for use before elective surgery to estimate the risk of postoperative pulmonary complications (GSU-Pulmonary Score): a development and validation study in three international cohorts.
BACKGROUND
Pulmonary complications are the most common cause of death after surgery. This study aimed to derive and externally validate a novel prognostic model that can be used before elective surgery to estimate the risk of postoperative pulmonary complications and to support resource allocation and prioritisation during pandemic recovery.
METHODS
Data from an international, prospective cohort study were used to develop a novel prognostic risk model for pulmonary complications after elective surgery in adult patients (aged ≥18 years) across all operation and disease types. The primary outcome measure was postoperative pulmonary complications at 30 days after surgery, which was a composite of pneumonia, acute respiratory distress syndrome, and unexpected mechanical ventilation. Model development with candidate predictor variables was done in the GlobalSurg-CovidSurg Week dataset (global; October, 2020). Two structured machine learning techniques were explored (XGBoost and the least absolute shrinkage and selection operator [LASSO]), and the model with the best performance (GSU-Pulmonary Score) underwent internal validation using bootstrap resampling. The discrimination and calibration of the score were externally validated in two further prospective cohorts: CovidSurg-Cancer (worldwide; February to August, 2020, during the COVID-19 pandemic) and RECON (UK and Australasia; January to October, 2019, before the COVID-19 pandemic). The model was deployed as an online web application. The GlobalSurg-CovidSurg Week and CovidSurg-Cancer studies were registered with ClinicalTrials.gov, NCT04509986 and NCT04384926.
FINDINGS
Prognostic models were developed from 13 candidate predictor variables in data from 86 231 patients (1158 hospitals in 114 countries). External validation included 30 492 patients from CovidSurg-Cancer (726 hospitals in 75 countries) and 6789 from RECON (150 hospitals in three countries). The overall rates of pulmonary complications were 2·0% in derivation data, and 3·9% (CovidSurg-Cancer) and 4·7% (RECON) in the validation datasets. Penalised regression using LASSO had similar discrimination to XGBoost (area under the receiver operating curve [AUROC] 0·786, 95% CI 0·774-0·798 vs 0·785, 0·772-0·797), was more explainable, and required fewer covariables. The final GSU-Pulmonary Score included ten predictor variables and showed good discrimination and calibration upon internal validation (AUROC 0·773, 95% CI 0·751-0·795; Brier score 0·020, calibration in the large [CITL] 0·034, slope 0·954). The model performance was acceptable on external validation in CovidSurg-Cancer (AUROC 0·746, 95% CI 0·733-0·760; Brier score 0·036, CITL 0·109, slope 1·056), but with some miscalibration in RECON data (AUROC 0·716, 95% CI 0·689-0·744; Brier score 0·045, CITL 1·040, slope 1·009).
INTERPRETATION
This novel prognostic risk score uses simple predictor variables available at the time of a decision for elective surgery that can accurately stratify patients' risk of postoperative pulmonary complications, including during SARS-CoV-2 outbreaks. It could inform surgical consent, resource allocation, and hospital-level prioritisation as elective surgery is upscaled to address global backlogs.
FUNDING
National Institute for Health Research.
Topics: Humans; Elective Surgical Procedures; Postoperative Complications; Female; Prognosis; Middle Aged; Male; Prospective Studies; Aged; COVID-19; Risk Assessment; Adult; Machine Learning; Risk Factors; Lung Diseases; Cohort Studies
PubMed: 38906616
DOI: 10.1016/S2589-7500(24)00065-7 -
Medicine Jun 2024This study aims to evaluate the safety and efficacy of endoscopic thyroid cancer treatment using an axillary approach. Participants were allocated into 2 groups: one...
This study aims to evaluate the safety and efficacy of endoscopic thyroid cancer treatment using an axillary approach. Participants were allocated into 2 groups: one undergoing transaxillary endoscopic surgery and the other, traditional open surgery. We compared intraoperative and postoperative conditions, focusing on parameters such as intraoperative blood loss, duration of surgery, length of postoperative hospitalization, volume of postoperative drainage, number of lymph nodes cleared in the central region, neck pain scores, neck injury indices, cosmetic satisfaction, postoperative complications, and total hospitalization duration. Patients in the endoscopic treatment (ET) group experienced longer surgical times, less intraoperative bleeding, and increased postoperative drainage. These indicators showed significant differences between the groups (P < .05). For the group undergoing endoscopic surgery via the axillary approach, there was a lower neck pain score on the third postoperative day and higher cosmetic satisfaction at 3 months. However, there were no significant differences between the groups in terms of the number of lymph nodes cleared in the central area, and the incidence of complications such as difficulty breathing, difficulty swallowing, hoarseness, and subcutaneous hematoma (P > .05). The axillary approach endoscopic surgery group also showed significantly prolonged surgery times and postoperative hospital stays, with a significant increase in postoperative drainage fluid (P < .05). Concurrently, this technique involved smaller surgical incisions and effectively concealed scars in the armpit, leading to better outcomes in terms of intraoperative bleeding, neck pain scores, and postoperative cosmetic satisfaction. Non-inflatable ET via the axillary approach for treating thyroid cancer demonstrates promising efficacy and safety. It offers additional benefits of minimal pain and enhanced cosmetic outcomes, making it a viable option for clinical adoption and application.
Topics: Humans; Thyroid Neoplasms; Thyroidectomy; Female; Male; Endoscopy; Adult; Axilla; Middle Aged; Operative Time; Postoperative Complications; Length of Stay; Treatment Outcome; Blood Loss, Surgical; Patient Satisfaction
PubMed: 38905368
DOI: 10.1097/MD.0000000000038507 -
Medicine Jun 2024The purpose of this study was to thoroughly evaluate the clinical features and surgical options for high-grade squamous intraepithelial lesions (HSIL) in postmenopausal...
Analysis of the clinical characteristics and surgical methods of high-grade squamous intraepithelial lesions of the cervix in postmenopausal women: A retrospective case study.
The purpose of this study was to thoroughly evaluate the clinical features and surgical options for high-grade squamous intraepithelial lesions (HSIL) in postmenopausal women. A total of 308 patients diagnosed with HSIL through colposcopic cervical biopsy and endocervical curettage were included. Their clinical characteristics, surgical treatments, and postoperative pathology were analyzed. Key findings include: 1. Patients with positive preoperative thinprep cytologic test (TCT) results and postoperative pathology indicating HSIL or squamous cell carcinoma (≥HSIL) were significantly more frequent than those with negative preoperative TCT results (P < .05). 2. Univariate analysis indicated significant impacts of TCT, human papillomavirus (HPV) type, transformation zone (TZ) location, and surgical technique on postoperative pathology (P < .05). 3. Logistic regression analysis confirmed significant influences of TCT, HPV type, TZ location, and surgical method on postoperative pathology outcomes (P < .05), showing that each unit increase in TZ raised the probability of ≥HSIL in postoperative pathology by 49.7%. In surgical comparisons, cold knife conization (CKC) and extrafascial hysterectomy resulted in 8.379 and 4.427 times higher probabilities of ≥HSIL in postoperative pathology, respectively, compared to loop electrosurgical excision procedure (LEEP). 4. Surgical methods significantly influenced margin results (P < .05). After LEEP, 17.5% of cases had positive margins, compared to 9.4% after CKC, and 3.7% after extrafascial hysterectomy, indicating the highest rate of positive surgical margins occurred with LEEP. 1. Combined TCT and HPV screening is crucial for cervical cancer prevention, early detection, and management in postmenopausal women. Women with positive results for both TCT and HPV should undergo colposcopic cervical biopsy and endocervical curettage. 2. For patients with TZ3, CKC is the recommended surgical option. 3. CKC is the preferred treatment for postmenopausal women with HSIL, as it effectively diagnoses and treats the lesion, showing superior outcomes in managing postmenopausal HSIL.
Topics: Humans; Female; Retrospective Studies; Middle Aged; Postmenopause; Uterine Cervical Neoplasms; Squamous Intraepithelial Lesions of the Cervix; Aged; Conization; Colposcopy; Hysterectomy; Papillomavirus Infections; Cervix Uteri; Biopsy; Uterine Cervical Dysplasia; Carcinoma, Squamous Cell
PubMed: 38905358
DOI: 10.1097/MD.0000000000038657