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JAMA Oct 2018Despite recent studies suggesting arthroscopic partial meniscectomy (APM) is not more effective than physical therapy (PT), the procedure is still frequently performed... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Despite recent studies suggesting arthroscopic partial meniscectomy (APM) is not more effective than physical therapy (PT), the procedure is still frequently performed in patients with meniscal tears.
OBJECTIVE
To assess whether PT is noninferior to APM for improving patient-reported knee function in patients with meniscal tears.
DESIGN, SETTING, AND PARTICIPANTS
Noninferiority, multicenter, randomized clinical trial conducted in 9 hospitals in the Netherlands. Participants were aged 45 to 70 years with nonobstructive meniscal tears (ie, no locking of the knee joint). Patients with knee instability, severe osteoarthritis, and body mass index greater than 35 were excluded. Recruitment took place between July 17, 2013, and November 4, 2015. Participants were followed up for 24 months (final participant follow-up, October 11, 2017).
INTERVENTIONS
Three hundred twenty-one participants were randomly assigned to APM (n = 159) or a predefined PT protocol (n = 162). The PT protocol consisted of 16 sessions of exercise therapy over 8 weeks focused on coordination and closed kinetic chain strength exercises.
MAIN OUTCOMES AND MEASURES
The primary outcome was change in patient-reported knee function on the International Knee Documentation Committee Subjective Knee Form (range, 0 to 100; from worse to best) from baseline over a 24-month follow-up period. The noninferiority margin was defined as a difference between treatment groups of 8 points and was assessed with a 1-sided α of .025. The primary analysis followed the intention-to-treat principle.
RESULTS
Among 321 patients who were randomized (mean [SD] age, 58 [6.6] years; 161 women [50%]), 289 (90%) completed the trial (161 women and 158 men). In the PT group, 47 participants (29%) had APM during the 24-month follow-up period, and 8 participants randomized to APM (5%) did not have APM. Over a 24-month follow-up period, knee function improved in the APM group by 26.2 points (from 44.8 to 71.5) and in the PT group by 20.4 points (from 46.5 to 67.7). The overall between-group difference was 3.6 points (97.5% CI, -∞ to 6.5; P value for noninferiority = .001). Adverse events occurred in 18 participants in the APM group and 12 in the PT group. Repeat surgery (3 in the APM group and 1 in the PT group) and additional outpatient visits for knee pain (6 in the APM group and 2 in the PT group) were the most frequent adverse events.
CONCLUSIONS AND RELEVANCE
Among patients with nonobstructive meniscal tears, PT was noninferior to APM for improving patient-reported knee function over a 24-month follow-up period. Based on these results, PT may be considered an alternative to surgery for patients with nonobstructive meniscal tears.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01850719.
Topics: Aged; Disease Progression; Female; Follow-Up Studies; Humans; Knee Joint; Male; Meniscectomy; Middle Aged; Osteoarthritis, Knee; Physical Therapy Modalities; Recovery of Function; Reoperation; Severity of Illness Index; Tibial Meniscus Injuries
PubMed: 30285177
DOI: 10.1001/jama.2018.13308 -
BMJ (Clinical Research Ed.) Sep 2019To evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in... (Comparative Study)
Comparative Study Observational Study Randomized Controlled Trial
Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial.
OBJECTIVE
To evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in the surgical treatment of uterine prolapse five years after surgery.
DESIGN
Observational follow-up of SAVE U (sacrospinous fixation versus vaginal hysterectomy in treatment of uterine prolapse ≥2) randomised controlled trial.
SETTING
Four non-university teaching hospitals, the Netherlands.
PARTICIPANTS
204 of 208 healthy women in the initial trial (2009-12) with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery who had been randomised to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. The women were followed annually for five years after surgery. This extended trial reports the results at five years.
MAIN OUTCOME MEASURES
Prespecified primary outcome evaluated at five year follow-up was recurrent prolapse of the uterus or vaginal vault (apical compartment) stage 2 or higher evaluated by pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. Secondary outcomes were overall anatomical failure (recurrent prolapse stage 2 or higher in apical, anterior, or posterior compartment), composite outcome of success (defined as no prolapse beyond the hymen, no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse), functional outcome, quality of life, repeat surgery, and sexual functioning.
RESULTS
At five years, surgical failure of the apical compartment with bothersome bulge symptoms or repeat surgery occurred in one woman (1%) after sacrospinous hysteropexy compared with eight women (7.8%) after vaginal hysterectomy with uterosacral ligament suspension (difference-6.7%, 95% confidence interval -12.8% to-0.7%). A statistically significant difference was found in composite outcome of success between sacrospinous hysteropexy and vaginal hysterectomy (89/102 (87%) 77/102 (76%). The other secondary outcomes did not differ. Time-to-event analysis at five years showed no differences between the interventions.
CONCLUSIONS
At five year follow-up significantly less anatomical recurrences of the apical compartment with bothersome bulge symptoms or repeat surgery were found after sacrospinous hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension. After hysteropexy a higher proportion of women had a composite outcome of success. Time-to-event analysis showed no differences in outcomes between the procedures.
TRIAL REGISTRATION
trialregister.nl NTR1866.
Topics: Adult; Aged; Aged, 80 and over; Female; Follow-Up Studies; Humans; Hysterectomy, Vaginal; Ligaments; Middle Aged; Netherlands; Quality of Life; Recurrence; Reoperation; Severity of Illness Index; Suture Techniques; Treatment Outcome; Uterine Prolapse
PubMed: 31506252
DOI: 10.1136/bmj.l5149 -
Orthopaedics & Traumatology, Surgery &... Feb 2019After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated... (Review)
Review
After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated with better outcomes. Failure of rotator cuff repair is perceived differently by the patient, by the surgeon, and in terms of social and occupational abilities. The work-up of failed cuff repair differs little from the standard work-up of cuff tears. Information must be obtained about the circumstances of the first repair procedure, a possible diagnostic inadequacy and/or technical error, and early or delayed trauma such as an aggressive rehabilitation programme. Most cuff retears do not require surgery, given their good clinical tolerance and stable outcomes over time. Repeat cuff repair, when indicated by pain and/or functional impairment, can improve pain and function. The quality of the tissues and time from initial to repeat surgery will influence the outcomes. The ideal candidate for repeat repair is a male, younger than 70 years of age, who is not seeking compensation, shows more than 90̊ of forwards elevation, and in whom the first repair consisted only in tendon suturing or reattachment. In addition to patient-related factors, the local conditions are of paramount importance in the decision to perform repeat surgery, notably repeat suturing. The most favourable scenario is a small retear with good-quality muscles and tendons and no osteoarthritis. When these criteria are not all present, several options deserve consideration as potentially capable of relieving the pain and, to a lesser extent, the functional impairments. They include the implantation of material (autograft, allograft, or substitute), a muscle transfer procedure, or reverse shoulder arthroplasty. However, the outcomes are poorer than when these options are used as the primary procedure. Prevention is the best treatment of cuff repair failure and involves careful patient selection and a routine analysis of the treatments that may be required by concomitant lesions. Biceps tenotomy should be considered on a case-by-case basis. Smoking cessation should be strongly encouraged and any metabolic disorders associated with repair failure should be brought under control.
Topics: Algorithms; Disability Evaluation; Esthetics; Humans; Medical History Taking; Muscle Weakness; Orthopedic Procedures; Pain; Patient Selection; Physical Examination; Postoperative Complications; Reoperation; Rotator Cuff Injuries; Shoulder Joint; Surgical Wound Infection; Treatment Failure; Wound Healing
PubMed: 30130661
DOI: 10.1016/j.otsr.2018.06.012 -
International Journal of Surgery... Apr 2020Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the most common procedures performed in bariatric surgery and both have been demonstrated... (Meta-Analysis)
Meta-Analysis
Comparative analysis of weight loss and resolution of comorbidities between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass: A systematic review and meta-analysis based on 18 studies.
BACKGROUND
Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are the most common procedures performed in bariatric surgery and both have been demonstrated to have significant effectiveness in treating morbid obesity. However, comparative analysis of their effectiveness has not been well studied. This comparative analysis was conducted to determine whether Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have the same mid- and long-term outcomes in weight loss, resolution of obesity comorbidities and adverse events (AEs) of treatment.
METHODS
We searched the Cochrane Library, PubMed, Embase and Web of Science databases from the establishment of the database to January 1, 2020 for both randomized control trials and non-randomised interventional studies that studied Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy with respect to weight loss outcomes, resolution of obesity comorbidities and AEs of treatment. Standardised mean differences, risk ratios and odds ratio with 95% confidence intervals were calculated to compare the outcomes of the groups. Two reviewers assessed the quality of the trials and extracted the data independently. All statistical analyses were performed using the standard statistical procedures in Review Manager 5.2.
RESULTS
We included 20 studies (N = 2917 participants) in this meta-analysis. Our results showed no significant difference in excess weight loss between Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, with pooled Standardised mean differences of -0.16 (95% confidence interval: -0.52 to 0.19; P = 0.36) based on randomized control trials and 0.07 (95% confidence interval: -0.10 to 0.24; P = 0.41) based on non-randomised interventional studies. Further, the pooled results showed no significant differences in midterm and long-term weight loss outcomes between the comparative groups. Similarly, no significant difference was found in type 2 diabetes mellitus resolution. The pooled results indicated that patients receiving laparoscopic sleeve gastrectomy experienced fewer postoperative complication and reoperation rates, with pooled risk ratios of 1.66 (95% confidence interval: 1.33 to 2.07; P < 0.00001) and 1.73 (95% confidence interval: 1.14 to 2.62; P = 0.01), respectively. Laparoscopic Roux-en-Y gastric bypass was superior to laparoscopic sleeve gastrectomy in managing dyslipidemia, hypertension and gastroesophageal reflux disease.
CONCLUSIONS
The present meta-analysis indicated that both Laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy had the same effectiveness in resulting in excess weight loss and type 2 diabetes mellitus resolution. However, patients who received laparoscopic sleeve gastrectomy experienced fewer postoperative complication and reoperation rates than those who received Laparoscopic Roux-en-Y gastric bypass. Laparoscopic Roux-en-Y gastric bypass was superior in the management of dyslipidemia, hypertension and gastroesophageal reflux disease.
Topics: Comorbidity; Diabetes Mellitus, Type 2; Gastrectomy; Gastric Bypass; Gastroesophageal Reflux; Humans; Hypertension; Laparoscopy; Obesity, Morbid; Odds Ratio; Postoperative Complications; Reoperation; Second-Look Surgery; Weight Loss
PubMed: 32151750
DOI: 10.1016/j.ijsu.2020.02.035 -
Multimedia Manual of Cardiothoracic... Jul 2023An orthotopic heart transplant remains the gold standard treatment for patients with end-stage heart failure. Despite significant developments and the widespread use of...
An orthotopic heart transplant remains the gold standard treatment for patients with end-stage heart failure. Despite significant developments and the widespread use of durable mechanical circulation support, a small number of patients will be considered for a heart retransplant. In this video tutorial, we describe the strategy and technique for patients who have already received an orthotopic heart transplant and who undergo a cardiac retransplant with a modified bicaval anastomosis technique.
Topics: Humans; Reoperation; Heart Transplantation; Anastomosis, Surgical
PubMed: 37470829
DOI: 10.1510/mmcts.2023.043 -
Anaesthesia Aug 2021
Topics: Cardiac Surgical Procedures; Humans; Medical Audit; Reoperation; United Kingdom
PubMed: 33621372
DOI: 10.1111/anae.15449 -
Urology Feb 2022To determine if limited food access census tracts and food swamp census tracts are associated with increased risk for repeat kidney stone surgery. And to elucidate the...
OBJECTIVE
To determine if limited food access census tracts and food swamp census tracts are associated with increased risk for repeat kidney stone surgery. And to elucidate the relationship between community-level food retail environment relative to community-level income on repeat stone surgery over time.
METHODS
Data were abstracted from the University of California, San Francisco Information Commons. Adult patients were included if they underwent at least one urologic stone procedure. Census tracts from available geographical data were mapped using Food Access Research Atlas data from the United States Department of Agriculture Economic Research Service. Kaplan-Meier curves were employed to illustrate time to a second surgical procedure over 5 years, and log-rank tests were used to test for statistically significant differences. A multivariate Cox regression model was used to generate hazard ratios for undergoing second surgery by group.
RESULTS
A total of 1496 patients were included in this analysis. Repeat stone surgery occurred in 324 patients. Kaplan-Meier curves demonstrated a statistically significant difference in curves depicting patients living in low income census tracts (LICTs) vs those not living in LICTs (P <.001). On Cox regression models, patients in LICTs had significantly higher risk of undergoing repeat surgery (P = .011). Patients from limited food access census tracts and food swamp census tracts did not have a significantly higher adjusted risk of undergoing second surgery (P = .11 and P = .88, respectively).
CONCLUSION
Income more so than food access associates with increased risk of repeat kidney stone surgery. Further research is needed to explore the interaction between low socioeconomic status and kidney stone outcomes.
Topics: Adult; Female; Humans; Income; Kidney Calculi; Male; Reoperation; United States
PubMed: 34813836
DOI: 10.1016/j.urology.2021.11.010 -
World Neurosurgery May 2024Surgery can effectively treat Trigeminal neuralgia (TN), but postoperative pain recurrence or nonresponse are common. Repeat surgery is frequently offered but limited... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Surgery can effectively treat Trigeminal neuralgia (TN), but postoperative pain recurrence or nonresponse are common. Repeat surgery is frequently offered but limited data exist to guide the selection of salvage surgical procedures. We aimed to compare pain relief outcomes after repeat microvascular decompression (MVD), percutaneous rhizotomy (PR), or stereotactic radiosurgery (SRS) to determine which modality was most efficacious for surgically refractory TN.
METHODS
A PRISMA systematic review and meta-analysis was performed, including studies of adults with classical or idiopathic TN undergoing repeat surgery. Primary outcomes included complete (CPR) and adequate (APR) pain relief at last follow-up, analyzed in a multivariate mixed-effect meta-regression of proportions. Secondary outcomes were initial pain relief and facial numbness.
RESULTS
Of 1299 records screened, 61 studies with 68 treatment arms (29 MVD, 14 PR, and 25 SRS) comprising 2165 patients were included. Combining MVD, PR, and SRS study data, 68.8% achieved initial CPR after a repeat TN procedure. On average, 49.6% of the combined sample of MVD, PR, and SRS had CPR at final follow-up, which was on average 2.99 years postoperatively. The proportion (with 95% CI) achieving CPR at final follow-up was 0.57 (0.51-0.62) for MVD, 0.60 (0.52-0.68) for PR, and 0.35 (0.30-0.41) for SRS, with a significantly lower proportion of pain relief with SRS. Estimates of initial CPR for MVD were 0.82 (0.78-0.85), 0.68 for PR (0.6-0.76), and 0.41 for SRS (0.35-0.48).
CONCLUSIONS
Across MVD, PR, and SRS, about half of TN patients maintain complete CPR at an average follow-up time of 3 years after repeat surgery. In treating refractory or recurrent TN, MVD and PR were superior to SRS in both initial pain relief and long-term pain relief at final follow-up. These findings can inform surgical decision-making in this challenging population.
Topics: Trigeminal Neuralgia; Humans; Microvascular Decompression Surgery; Reoperation; Rhizotomy; Radiosurgery; Recurrence; Treatment Outcome
PubMed: 38403014
DOI: 10.1016/j.wneu.2024.02.097 -
Epilepsia Dec 2017Medically refractory epilepsy is a debilitating disorder that is particularly challenging to treat in patients who have already failed a surgical resection. Evidence... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Medically refractory epilepsy is a debilitating disorder that is particularly challenging to treat in patients who have already failed a surgical resection. Evidence regarding outcomes of further epilepsy surgery is limited to small case series and reviews. Therefore, our group performed the first quantitative meta-analysis of the literature from the past 30 years to assess for rates and predictors of successful reoperations.
METHODS
A PubMed search was conducted for studies reporting outcomes of repeat epilepsy surgery. Studies were excluded if they reported fewer than five eligible patients or had average follow-ups < 1 year, and patients were excluded from analysis if they received a nonresective intervention. Outcomes were stratified by each variable of interest, and quantitative meta-analysis was performed to generate odds ratios (ORs) and 95% confidence intervals (CIs).
RESULTS
Seven hundred eighty-two patients who received repeat resective epilepsy surgery from 36 studies were included. Engel I outcome was observed in 47% (n = 369) of patients. Significant predictors of seizure freedom included congruent over noncongruent electrophysiology data (OR = 3.6, 95% CI = 1.6-8.2), lesional over nonlesional epilepsy (OR = 3.2, 95% CI = 1.9-5.3), and surgical limitations over disease-related factors associated with failure of the first surgery (OR = 2.6, 95% CI = 1.3-5.3). Among patients with at least one of these predictors, seizure freedom was achieved in 58%. Conversely, the use of invasive monitoring was associated with worse outcome (OR = 0.4, 95% CI = 0.2-0.9). Temporal lobe over extratemporal/multilobe resection (OR = 1.5, 95% CI = 0.8-3.0) and abnormal over normal preoperative magnetic resonance imaging (OR = 1.9, 95% CI = 0.6-5.4) showed nonsignificant trends toward seizure freedom.
SIGNIFICANCE
This analysis supports considering further resection in patients with intractable epilepsy who continue to have debilitating seizures after an initial surgery, especially in the context of factors predictive of a favorable outcome.
Topics: Drug Resistant Epilepsy; Electroencephalography; Humans; Reoperation; Treatment Outcome
PubMed: 28994113
DOI: 10.1111/epi.13920 -
World Journal of Gastroenterology Jan 2015To assess clinical outcomes of laparoscopic hepatectomy (LH) in patients with a history of upper abdominal surgery and repeat hepatectomy. (Comparative Study)
Comparative Study Observational Study
AIM
To assess clinical outcomes of laparoscopic hepatectomy (LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.
METHODS
This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery. Of the 80 patients who underwent LH, 22 had prior abdominal surgeries, including hepatectomy (n = 12), pancreatectomy (n = 3), cholecystectomy and common bile duct excision (n = 1), splenectomy (n = 1), total gastrectomy (n = 1), colectomy with the involvement of transverse colon (n = 3), and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen (n = 1). Clinical indicators including operating time, blood loss, hospital stay, and morbidity were compared among the groups.
RESULTS
Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver. However, there were no conversions to laparotomy in this group. In the 58 patients without a history of upper abdominal surgery, the median operative time was 301 min and blood loss was 150 mL. In patients with upper abdominal surgical history or repeat hepatectomy, the operative times were 351 and 301 min, and blood loss was 100 and 50 mL, respectively. The median postoperative stay was 17, 13 and 12 d for patients with no history of upper abdominal surgery, patients with a history, and patients with repeat hepatectomy, respectively. There were five cases with complications in the group with no surgical history, compared to only one case in the group with a prior history. There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history, or with repeat hepatectomy.
CONCLUSION
LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.
Topics: Abdomen; Aged; Aged, 80 and over; Blood Loss, Surgical; Feasibility Studies; Female; Hepatectomy; Humans; Japan; Laparoscopy; Length of Stay; Male; Middle Aged; Operative Time; Peritoneal Diseases; Postoperative Complications; Reoperation; Time Factors; Tissue Adhesions; Treatment Outcome
PubMed: 25624731
DOI: 10.3748/wjg.v21.i3.961