Long-term Outcomes after Intersphincteric Resection for Low-Lying Rectal Cancer

Background

As an anus-preserving surgery for very low rectal cancer, intersphincteric resection (ISR), has advanced markedly over the last 20 years. We investigated long-term oncologic, functional, and quality of life (QOL) outcomes after ISR with or without partial external sphincter resection (PESR).

Methods

A series of 199 patients underwent curative ISR with or without PESR between 2000 and 2008, with 49 receiving preoperative chemoradiotherapy (CRT group) and 150 undergoing surgery first (surgery group). Overall survival (OS), disease-free survival (DFS), and local relapse-free survival (LFS) rates were calculated using Kaplan–Meier methods. Functional outcomes were assessed using the Wexner incontinence score. QOL was investigated using the Short-Form 36 questionnaire (SF-36) and modified fecal incontinence quality of life (mFIQL) scale.

Results

After a median follow-up of 78 months (range 12–164 months), estimated 7-year OS, DFS, and LFS rates were 78, 67, and 80 %, respectively. LFS was better in the CRT group than in the surgery group (p = 0.045). Patients with PESR or positive circumferential resection margins showed significantly worse survival. The median Wexner incontinence score at >5 years was 8 in the surgery group and 10 in the CRT group (p = 0.01). QOL was improved in all physical and mental subscales of the SF-36 at >5 years. Although the mFIQL showed a relatively good score in all groups at >5 years, a significant difference existed between the CRT and surgery groups (p = 0.008).

Conclusions

With long-term follow-up, oncologic, functional, and QOL results after ISR appear acceptable, although CRT is associated with disturbance.     

Multimodal analgesic approach incorporating paravertebral blocks for open radical retropubic prostatectomy: a randomized double-blind placebo-controlled study

Introduction

Perioperative pain management influences both the quality as well as the speed of recovery following surgery.

Methods

This was a randomized double-blind placebo-controlled study designed to assess the effectiveness of a multimodal analgesic approach (MMA) vs patient-controlled analgesia (PCA) alone in patients undergoing open prostatectomy. Prior to surgery, paravertebral blocks (PVBs) were performed with either 0.5% ropivacaine in the MMA group or saline in the PCA group. Patients in the MMA group also received celecoxib (400 mg po prior to surgery and 200 mg po bid for seven days following surgery) and ketamine 10 mg iv. Following surgery, every patient had free access to morphine PCA. A pain numerical rating scale (NRS) at 24 hr was chosen as the primary endpoint. Secondary endpoints included morphine consumption at 24 hr and SF-36 (36-Item Short-Form Health Survey) scores from two weeks to 24 weeks following surgery.

Results

The primary endpoint, average pain NRS at 24 hr, was 2.6 in the MMA group compared with 3.9 in the PCA group (difference = ?1.6, 95% confidence interval [CI]: ?2.3 to ?0.4; P = 0.01). The average morphine consumption at 24 hr was 4.8 mg in the MMA group compared with 10.5 mg in the PCA group (difference = ?5.7, 95% CI: ?13.0 to 0.5; P = 0.01). Higher SF-36 scores at two, four, eight, and 12 weeks were observed in the MMA group compared with the PCA group, but no statistically significant (P < 0.05) between-group difference was found after Bonferroni correction of comparisons conducted repeatedly over time. Postoperative adverse effects included low episodes of postoperative nausea and vomiting, bladder spasms, constipation, and pruritus.

Conclusion

This study demonstrates that PVBs combined with celecoxib and ketamine provide better immediate postoperative pain control and facilitate earlier functional recovery in patients undergoing an open radical prostatectomy when compared with PCA alone.     

Predictors of health-related quality of life in neurosurgical brain tumor patients: focus on patient-centered perspective

Background

In brain tumor (BT) patients, the association between health-related quality of life (HRQoL) and psychological characteristics remains largely unknown. We evaluated the association of personality traits, clinical factors, psychological distress symptoms, and cognitive state with HRQoL in BT patients.

Methods

On admission for BT surgery, 200 patients (69 % women; age 55.8?±?14.5 years) were evaluated for HRQoL (SF-36 scale), Big-Five personality traits (Ten-Item Personality Inventory), psychological distress symptoms (Hospital Anxiety and Depression Scale or HADS), cognitive function (Mini-Mental State Examination or MMSE) and clinical characteristics, including functional status (Barthel index or BI). The most common BT diagnoses were meningioma (39 %) and high-grade glioma (18 %).

Results

Only factors significantly associated with SF-36 domains in univariable regression analyses were included in their respective multivariable models and predicted from 6 %–49 % of the total variance of SF-36 scores. Greater TIPI emotional stability score was independently associated with greater SF-36 emotional well-being (β?=?0.23, p?<?0.001) and general health (β?=?0.18, p?=?0.01) scores, and greater TIPI consciousness score, with greater SF-36 emotional well-being score (β?=?0.13, p?=?0.02). HADS-anxiety and HADS-depression scores were the strongest independent determinants of all, except physical functioning, SF-36 scores (β-values range from 0.14 to 0.56; p values?≤?0.03). BI score was the strongest independent determinant of SF-36 physical functioning score (β?=?0.36, p?<?0.001). MMSE score was associated with all but emotional well-being and social functioning SF-36 scores.

Conclusions

Consciousness and emotional stability should be considered important personality-related determinants of HRQoL in BT patients. Psychological distress, functional disability, and cognitive impairment are also important predictors of HRQoL.     

Clinical outcomes of minimally invasive versus open approach for one-level transforaminal lumbar interbody fusion at the 3- to 4-year follow-up

Purpose

Supporters of minimally invasive approaches for transforaminal lumbar interbody fusion (TLIF) have reported short-term advantages associated with a reduced soft tissue trauma. Nevertheless, mid- and long-term outcomes and specifically those involving physical activities have not been adequately studied. The aim of this study was to compare the clinical outcomes of mini-open versus classic open surgery for one-level TLIF, with an individualized evaluation of the variables used for the clinical assessment.

Methods

A prospective cohort study was conducted of 41 individuals with degenerative disc disease who underwent a one-level TLIF from January 2007 to June 2008. Patients were randomized into two groups depending on the type of surgery performed: classic open (CL-TLIF) group and mini-open approach (MO-TLIF) group. The visual analog scale (VAS), North American Spine Society (NASS) Low Back Pain Outcome instrument, Oswestry Disability Index (ODI) and the Short Form 36 Health Survey (SF-36) were used for clinical assessment in a minimum 3-year follow-up (36–54 months).

Results

Patients of the MO-TLIF group presented lower rates of lumbar (p = 0.194) and sciatic pain (p = 0.427) and performed better in daily life activities, especially in those requiring mild efforts: lifting slight weights (p = 0.081), standing (p = 0.097), carrying groceries (p = 0.033), walking (p = 0.069) and dressing (p = 0.074). Nevertheless, the global scores of the clinical questionnaires showed no statistical differences between the CL-TLIF and the MO-TLIF groups.

Conclusions

Despite an improved functional status of MO-TLIF patients in the short term, the clinical outcomes of mini-open TLIF at the 3- to 4-year follow-up showed no clinically relevant differences to those obtained with open TLIF.     

Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty

Introduction

Fracture sequelae (FS) of the proximal humerus is a challenging scenario in shoulder surgery. Despite they have been traditionally treated with hemiarthroplasty (HA), the use of reverse shoulder arthroplasty (RSA) has been recently introduced. However, there are no studies comparing the results of HA and RSA in FS. The purpose of this study was to compare the functional and quality of life-related outcomes, and complications in the treatment of proximal humeral FS between HA and RSA.

Materials and methods

A therapeutic prospective non-randomized comparative study was conducted. All consecutive patients with diagnosis of FS after non-operative treatment of proximal humeral fractures and no previous shoulder surgery were considered for this study. A total of 32 patients (24 females, 8 males) with a mean (SD) age at the time of surgery of 80.1 (4.9) years were finally included: 12 in the HA group, and 20 in the RSA group. FS were treated with shoulder arthroplasty by the implantation of either HA or RSA. Constant score (total and specific items), quality of life (assessed through SF-36), and complications requiring revision surgery were compared between groups.

Results

All parameters of the Constant score significantly improved in the postoperative compared to preoperative period when considering the entire sample. The RSA group demonstrated a higher improvement in total Constant score (p = 0.06) and Constant activity level (p = 0.02) compared to the HA group. The HA demonstrated a higher number of complications compared to the RSA (p = 0.05). There were no differences in SF-36 scores between both groups.

Conclusions

The shoulder arthroplasty is an effective treatment for FS with significant improvement in pain and function. The RSA may be a better option than HA for FS given the trend towards better total Constant score and a significantly lower number of complications requiring revision surgery.

Level of evidence

Therapeutic level II evidence.     

Meta-Analysis of Efficacy and Safety of Fast-Track Surgery in Gastrectomy for Gastric Cancer

Background

Fast-track surgery (FTS) is a promising program for surgical patients and has been applied to several surgical diseases. FTS is much superior to conventional perioperative care. Our aim was to evaluate and compare the safety and efficacy of FTS and conventional perioperative care for patients undergoing gastrectomy using a systematic review.

Methods

We searched the literature in PubMed, SCOPUS, and EMBASE up to November 2013. No language restriction was applied. Weighted mean differences (WMDs) and odds ratios (ORs) with their 95 % confidence intervals (CIs) were used for analysis by a fixed or a random effects model according to the heterogeneity assumption.

Results

In the present meta-analysis, we included five randomized controlled trials and one controlled clinical trial from five studies. Compared with conventional care, FTS shortened the duration of flatus (WMD ?21.08; 95 % CI ?27.46 to ?14.71, z = 6.48, p < 0.00001 in the open surgery group; WMD ?8.20; 95 % CI ?12.87 to ?3.53, z = 3.44, p = 0.0006 in the laparoscopic surgery group), accelerated the decrease in C-reactive protein (WMD ?15.56; 95 % CI 21.28 to 9.83, z = 5.33, p < 0.00001), shortened the postoperative stay (WMD ?2.00; 95 % CI ?2.69 to ?1.30, z = 5.64, p < 0.00001), and reduced hospitalization costs (WMD ?447.72; 95 % CI ?615.92 to ?279.51, z = 5.22, p < 0.00001). FTS made no significant difference in operation times (p = 0.93), intraoperative blood loss (p = 0.79), or postoperative complications (p = 0.07).

Conclusions

Based on current evidence, the FTS protocol was feasible for gastric cancer patients who underwent gastrectomy (distal subtotal gastrectomy, proximal subtotal gastrectomy, or radical total gastrectomy) via open or laparoscopic surgery. Larger studies are needed to validate our findings.     

Comparison of unilateral versus bilateral pedicle screw fixation in degenerative lumbar diseases: a meta-analysis

Purpose

Traditionally, lumbar spinal surgery is performed with bilateral pedicle screw fixation to provide stability as the fusion heals. However, many studies have reported that unilateral pedicle screw fixation is as effective as bilateral constructs. To compare the clinical outcomes, complications, and surgical trauma between the two techniques for treatment of degenerative lumbar diseases, we conducted a meta-analysis.

Methods

We searched MEDLINE, EMBASE, PubMed, Google Scholar, and Cochrane databases for relevant controlled studies up to August 2013 that compared unilateral with bilateral fixation for the treatment of degenerative lumbar diseases. We independently performed title/abstract screening and full-text screening. A random effects model was used for heterogeneous data; otherwise, a fixed effect model was used, pooling data using mean difference (MD) for continuous outcomes and odds ratio (OR) for dichotomous outcomes.

Results

A total of 12 articles (865 participants) were eligible. Overall, there were significant differences between the two groups for blood loss (MD = ?171.73, 95 % CI = ?281.70 to ?61.76; p = 0.002), operation time (MD = ?66.02, 95 % CI = ?115.52 to ?16.51; p = 0.009), and fusion rate (OR = 0.50, 95 % CI = 0.26–0.96; p = 0.004). However, there were no significant differences in hospital stay (MD = ?4.44, 95 % CI = ?13.37 to 4.50), ODI (MD = ?0.09, 95 % CI = ?0.59 to 0.42; p = 0.74), JOA (MD = 0.18, 95 % CI = ?0.77 to 1.14; p = 0.71), VAS (MD = ?0.04, 95 % CI = ?0.16 to 0.08; p = 0.49), SF-36 (PF: MD = ?1.11, 95 % CI = ?4.38 to 2.17, p = 0.51; GH: MD = 1.22, 95 % CI = ?2.17 to 4.60, p = 0.48; MH: MD = ?0.22, 95 % CI = ?3.83 to 3.38, p = 0.90) and complications (OR = 1.15, 95 % CI = 0.72–1.85; p = 0.56).

Conclusions

This meta-analysis shows that there was significantly less blood loss in unilateral group and less operating time; however, the fusion rate was significantly higher in the bilateral group. The outcomes of hospital stay, ODI, JOA, VAS, SF-36 score, and complications are similar in the two groups.     

Enhanced Recovery Pathway for Urgent Colectomy

Background

Enhanced recovery protocols have been proven to decrease complications and hospital stay following elective colorectal surgery. However, these principles have not yet been reported for urgent surgery procedures. We aimed to assess our initial experience with urgent colectomies performed within an established enhanced recovery pathway.

Methods

In a prospective cohort study, all patients undergoing colonic resection between April 2012 and March 2013 were treated according to a standardized enhanced recovery protocol. Urgent surgeries were compared with the elective procedures with regards to baseline characteristics, compliance with enhanced recovery items, and clinical outcome.

Results

Patients (N = 28) requiring urgent colonic resection were included and compared with patients undergoing elective colectomy (N = 63). Overall compliance with the protocol was 57 % for the urgent compared with 77 % for the elective procedures (p = 0.006). The pre-operative compliance was 64 versus 96 % (p < 0.001), the intra-operative compliance was 77 versus 86 % (p = 0.145), and the post-operative compliance was 49 versus 67 % (p = 0.015), for the urgent and elective resections, respectively. Overall, 18 urgent patients (64 %) and 32 elective patients (51 %) developed postoperative complications (p = 0.261). Median postoperative length of stay was 8 days in the urgent setting compared with 5 days in the elective setting (p = 0.006).

Conclusions

Many of the intra-operative and post-operative enhanced recovery items can also be applied to urgent colectomy, entailing outcomes that approach the results achieved in the elective setting.     

Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of acute and chronic cases

Introduction

To verify the usefulness of and optimal timing for conducting anterior cruciate ligament (ACL) reconstruction, we evaluated and compared baseline characteristics and surgical outcomes in patients with ACL injury divided into acute and chronic groups.

Patients and methods

101 patients after ACL reconstruction were studied. Patients who underwent surgery within 8 weeks after injury were classified as acute group (n = 40), and those having surgery after 8 weeks as chronic group (n = 61). SF-36, VAS, Lysholm score, anterior tibial translation, and pivot shift were assessed before surgery and 6, 18 and 30 months after surgery. The results of two groups were compared.

Results

In the preoperative SF-36 survey, physical and mental health scores were lower than the national standard scores in both groups. Physical health score was significantly lower in acute group, although mental health score was not significantly different between two groups. Preoperative VAS and Lysholm score were significantly poorer in acute group compared to chronic group. However, preoperative anterior tibial translation and pivot shift were not significantly different between the two groups. In postoperative evaluations, all parameters were improved significantly compared to preoperative values in both groups, and no significant differences were observed between the two groups.

Discussion

All evaluation methods showed significant improvements after surgery in both acute and chronic groups, confirming that ACL reconstruction is useful for both acute and chronic injuries. However, preoperative evaluations by SF-36, VAS, and Lysholm scale yielded different results in two groups, indicating the need to evaluate acute and chronic cases separately. Development of a specific evaluation method that is valid for any duration from injury to surgery is desirable.     

Comparing the outcomes between Chopart,Lisfranc and multiple metatarsal shaft fractures

Objectives

Complex midfoot injuries could lead to severe functional impairment of mobility and quality of daily living. Aim of this study was to compare the clinical and functional outcomes of Chopart, Lisfranc fractures and multiple metatarsal shaft fractures.

Design

Retrospective case series.

Setting

Level one trauma center.

Intervention

Open or closed reduction and internal fixation with screws, K-wires, plates, external fixation or combination of different technics.

Main outcome measurements

The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Maryland Foot Score were used to assess pain and functional outcome. 3D gait analysis, pedobarographic analysis and radiologic examinations were performed. The activity level was measured by a step counting accelerometer. All results were compared to an age-matched healthy control group.

Results

24 patients with a median age of 44 years (16–72) were included: 12 patients with multiple metatarsal shaft fractures, 6 patients with Chopart and 6 patients with Lisfranc fractures. The median follow-up was 2.6 years. The pedobarographic analysis reports reduced contact time of the total foot (p = 0.08), the forefoot (p = 0.008) and the hallux (p = 0.015) for the injured foot. A median score of 64 for the SF-36, 64 for the AOFAS Midfoot Score and 73 for the Maryland Foot Score indicated a poor restoration of foot function. Multiple metatarsal shaft fractures presented a significantly lower walking speed (p = 0.03) and cadence (p = 0.04).

Conclusion

The worst results were reported for multiple metatarsal shaft fractures on outcome scores, pedobarography, gait analysis and activity. Metatarsal serial fractures should not be underestimated as well as Chopart and Lisfranc fractures.

Level of evidence

Level IV.     

Early rehabilitation versus conventional care after laparoscopic rectal surgery: a prospective, randomized, controlled trial

Background

Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial.

Methods

Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36.

Results

The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107–188] vs. conventional, 146.5 h [115–183], p = 0.47; 7.5 days [7–11] vs. 8.0 days [7–10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups.

Conclusions

This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).     

Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach

Purpose

Obturator hernia is a rare disease and preoperative diagnosis is always difficult. There are increasing reports employing laparoscopic approach in the recent literature. Our aim was to review and compare the open and laparoscopic approach in repairing obturator hernia.

Methods

All patients with obturator hernia from 1997 to 2011 were recruited. Patient’s demographics, presentation, operative details, morbidity, and mortality were retrospectively collected and reviewed.

Results

There were 36 patients during the 15-year period. All of them were elderly ladies (median 83). Nineteen underwent open surgery while 16 received laparoscopic surgery. Both age and ASA were comparable. The median operative time was 68 and 65 min for laparoscopic and open group, respectively (p = 0.690). The median hospital stay was significantly longer in the open group (19 vs 5 days, p = 0.007). There were less major complications (p = 0.004) and mortality (p = 0.049) in the laparoscopic group. Two recurrences were reported in the laparoscopic group, although statistically not significant (p = 0.202).

Conclusions

Laparoscopic repair can achieve a shorter hospital stay and has lesser major complications and mortality in selected patients.     

Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study

Objective

To assess health-related quality of life (HRQOL) in a prospective study with 7?years of follow-up in 49 consecutive patients who underwent a total joint replacement because of osteoarthritis.

Methods

Generic HRQOL was assessed with the short-form 36 (SF-36) and specific HRQOL with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results

Out of the 39 subjects who have completed the 7?years of follow-up of this study, 22 (56.4?%) underwent a hip replacement surgery and the other 17 (43.6?%) a knee replacement. Six months after surgery, a significant improvement, compared to preoperative scores, was observed in two of the eight dimensions of the SF-36 (i.e. physical function and pain). The same dimensions, pain and physical function, at the same time, 6?months after surgery, measured by the WOMAC, showed a significant improvement as well, but there was no significant change in the stiffness score. From 6?months to the end of follow-up, changes in SF-36 scores showed a significant improvement in physical function (p?=?0.008), role-physical (p?=?0.004) and role-emotional (p?=?0.01) while all scores of the WOMAC improved (p?<?0.001 for pain, p?<?0.001 for stiffness and p?<?0.01 for physical function).

Conclusion

The improvements observed in HRQOL at short term after surgery, are at least maintained over a 7-year follow-up period.     

The Impact of Skin Grafting on the Quality of Life and Self-Esteem of Patients with Venous Leg Ulcers

Background

The assessment of health-related quality of life in patients with venous leg ulcers provides important information for clinical decision making, evaluation of therapeutic benefits, and prediction of survival probabilities.

Methods

Health-related quality of life and self-esteem were assessed using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Rosenberg self-esteem (RSE) scale, respectively, in patients with venous leg ulcers treated with split-thickness skin grafts. One hundred patients with venous leg ulcers and indication for skin grafting were divided into two groups of 50 patients each: the control group (patients who received conservative treatment) and surgery group (patients who received split-thickness skin grafts).

Results

Patients in the surgery group reported significantly higher SF-36 scores (better health status) than controls one month after surgery, as well as 90 and 180 days postoperatively (p < 0.002). The mean total RSE score was significantly lower (indicating higher self-esteem) in the surgery group (mean RSE score, 17.54) than in the control group (mean RSE score, 24.22).

Conclusions

Split-thickness skin grafting resulted in better health-related quality of life and self-esteem in patients with venous leg ulcers than did compression therapy with Unna’s boot.     

Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study

Background

Patients undergoing colorectal cancer resections are at risk for delayed recovery. Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery. The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone. They propose an expanded trimodal prehabilitation program that adds nutritional counseling, protein supplementation, and anxiety reduction to a moderate exercise program. This study aimed to estimate the impact of this trimodal program on the recovery of functional capacity compared with standard surgical care.

Methods

Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period. The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began. The primary outcome was functional walking capacity (6-min walk test [6MWT]). The secondary outcomes included self-reported physical activity (CHAMPS questionnaire) and health-related quality of life (SF-36). Data are expressed as mean ± standard deviation or median (interquartile range [IQR]) and were analyzed using Chi-square and Student’s t test. All p values lower than 0.05 were considered significant.

Results

The prehabilitation and control groups were comparable in terms of age, gender, body mass index (BMI) and American Society of Anesthesiology (ASA) class. There was no difference in walking capacity at the first assessment (6MWT distance, 422 ± 87 vs 402 ± 57 m; p = 0.21). During the prehabilitation period lasting a median of 33 days (range, 21–46 days), functional walking capacity improved by 40 ± 40 m (p < 0.01). The postoperative complication rates and the hospital length of stay were similar. The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks (mean difference, 51.5 ± 93 m; p = 0.01) and 8 weeks (mean difference, 84.5 ± 83 m; p < 0.01). At 8 weeks, 81 % of the prehabilitated patients were recovered compared with 40 % of the control group (p < 0.01). The prehabilitation group also reported higher levels of physical activity before and after surgery.

Conclusion

In this pilot study, a 1-month trimodal prehabilitation program improved postoperative functional recovery. A randomized trial is ongoing (NCT01356264).     

UltraPro Hernia System,Prolene Hernia System and Lichtenstein for primary inguinal hernia repair: 3-year outcomes of a prospective randomized controlled trial

Purpose

Chronic pain and discomfort are common after inguinal hernia repair (IHR). In this study, results from a 3-year follow-up from a randomized controlled study comparing three different mesh repairs for postoperative pain, discomfort, Quality of Life (QoL) and patient satisfaction are reported.

Methods

Between November 1, 2006 and January 31, 2009, 309 men, who underwent day surgery for primary unilateral inguinal hernia under local anesthesia, were randomized to three different mesh repairs; UltraPro Hernia System (U), Prolene Hernia System (P) and Lichtenstein procedure (L).

Results

Preoperatively, there were no differences between groups regarding demographics, symptoms, inguinal pain or QoL (SF-36 and a hernia-specific questionnaire). Operating time, postoperative pain, complications and time to full recovery were similar. At 36 months, 21 patients indicated pain [L, n = 6, P, n = 6 and U, n = 9; VAS (median (IQR)): L 0.4 (0.2–1.7), P 0.2 (0.1–2.3) and U 1.6 (0.7–4.6), p = ns]. Physical QoL was reduced in all groups before surgery and was similarly increased to normal levels after 3 months without further changes throughout the study. Although 92 % of participants were satisfied, sixteen percent reported any discomfort from the groin (ns between groups). Five recurrences were reported (L, n = 2, P, n = 1 and U, n = 2, p = ns).

Conclusions

After 3 years of follow-up, all three procedures provided equally good results regarding, pain, discomfort and QoL and could therefore be recommended for primary IHR in LA.

     

Morbidity of early spine surgery in the multiply injured patient

Introduction

The optimal timing of surgery for multiply injured patients with operative spinal injuries remains unknown. The purported benefits of early intervention must be weighed against the morbidity of surgery in the early post-injury period. The performance of spine surgery in the Afghanistan theater permits analysis of the morbidity of early surgery on military casualties. The objective is to compare surgical morbidity of early spinal surgery in multiply injured patients versus stable patients.

Materials and methods

Patients were retrospectively categorized as stable or borderline unstable depending on the presence of at least one of the following: ISS >40, ISS >20 and chest injury, exploratory laparotomy or thoracotomy, lactate >2.5 mEq/L, platelet <110,000/mm³, or >10 U PRBCs transfused pre-operatively. Surgical morbidity, complications, and neurologic improvement between the two groups were compared retrospectively.

Results

30 casualties underwent 31 spine surgeries during a 12-month period. 16 of 30 patients met criteria indicating a borderline unstable patient. Although there were no significant differences in the procedures performed for stable and borderline unstable patients as measured by the Surgical Invasiveness Index (7.5 vs. 6.9, p = 0.8), borderline unstable patients had significantly higher operative time (4.3 vs. 3.0 h, p = 0.01), blood loss (1,372 vs. 366 mL, p = 0.001), PRBCs transfused intra-op (3.88 vs. 0.14 U, p < 0.001), and total PRBCs transfused in theater (10.18 vs. 0.31 U, p < 0.001).

Conclusions

The results indicate that published criteria defining a borderline unstable patient may have a role in predicting increased morbidity of early spine surgery. The perceived benefits of early intervention should be weighed against the greater risks of performing extensive spinal surgeries on multiply injured patients in the early post-injury period, especially in the setting of combat trauma.     

A Model to Predict the Risk of Upgrade to Malignancy at Surgery in Atypical Breast Lesions Discovered on Percutaneous Biopsy Specimens

Background

When any atypical feature is identified on a percutaneous biopsy specimen of a suspicious breast lesion, surgical excision is mandatory, leading to unnecessary surgeries in 70–90 % of the cases. The purpose of this study was to develop a model to predict the presence of cancer at surgery that would be applicable to all atypical lesions.

Methods

We collected complete clinical, radiological, and double-reading histological data concerning all patients with a diagnosis of a pure atypical lesion on image-guided biopsy performed at the One-Stop Breast Care Unit between 2004 and 2011.

Results

Among the 204 eligible patients, 49 cancers (24 %) had been diagnosed at definitive surgery (20 ductal carcinoma in situ, 20 invasive ductal, and 9 invasive lobular carcinoma). The univariate analysis retrieved age (p = 0.03), the focus size in mm (p = 0.02), the number of biopsy cores (p = 0.02), the disappearance of radiological anomalies after biopsy (p = 0.05), the mean number of atypical foci (p = 0.05) and the percentage of atypical lobules and ducts for lobular neoplasia (p = 0.04) as factors associated with cancer at surgery, whereas neither Ki67 nor ALDH1 expression was significantly correlated. The final most informative nomogram comprised information on patient age, the disappearance of radiological anomalies after biopsy and a focus size >15 mm. For the optimal threshold (risk of cancer = 21 %), sensitivity, specificity, positive predictive value, and negative predictive value were 78, 66, 36, and 90 %, respectively.

Conclusions

After validation, this model could help to identify a subset of patients with premalignant disease who could be spared surgery.     

Comparison of minimally invasive fusion and instrumentation versus open surgery for severe stenotic spondylolisthesis with high-grade facet joint osteoarthritis

Purpose

The object of this study was to compare minimally invasive surgery (MIS) with open surgery in a severely affected subgroup of degenerative spondylolisthetic patients with severe stenosis (SDS) and high-grade facet osteoarthritis (FJO).

Methods

From January 2009 to February 2010, 49 patients with severe SDS and high-grade FJO were treated using either MIS or open TLIF. Intraoperative and diagnostic data, including perioperative complications and length of hospital stay (LOS), were collected, using retrospective chart review. Surgical short- and long-term outcomes were assessed according to the Oswestry disability index (ODI) and visual analog scale (VAS) for back and leg pain.

Results

Comparing MIS and open surgery, the MIS group had lesser blood loss, significantly lesser need for transfusion (p = 0.02), more rapid improvement of postoperative back pain in the first 6 weeks of follow-up and a shorter LOS. On the other hand, we experienced in the MIS group a longer operative time. The distribution on the postoperative ODI (p = 0.841), VAS leg (p = 0.943) and back pain (p = 0.735) scores after a mean follow-up of 2 years were similar. The overall proportion of complications showed no significant difference between the groups (29 % in the MIS group vs. 28 % in the open group, p = 0.999).

Conclusion

Minimally invasive surgery for severe SDS leads to adequate and safe decompression of lumbar stenosis and results in a faster recovery of symptoms and disability in the early postoperative period.