One-Step Multichannel Percutaneous Transhepatic Cholangioscopic Lithotripsy Applied in Bilateral Hepatolithiasis

Background

The aim of this study was to compare the outcomes of one-step multichannel percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) with traditional PTCSL in the treatment of bilateral hepatolithiasis.

Methods

From February 2011 to June 2015, 156 patients with bilateral hepatolithiasis received surgical treatment in our department. Among these patients, 81 received one-step multichannel PTCSL (group A), and the remaining 75 received traditional PTCSL (group B).

Results

Compared with group B, group A was characterized by a significantly shorter operation time (83.7 ± 28.5 min vs 118.1 ± 41.5 min; P = 0.000), hospital stay (11.1 ± 3.4 d vs 17.8 ± 5.6 d; P = 0.034), and postoperative hospital stay (6.9 ± 3.1 d vs 9.6 ± 4.5 d; P = 0.026). In addition, the immediate clearance (62.9% vs 45.3%, P = 0.027) and final clearance (90.1% vs 78.7%, P = 0.048) rates were higher in group A than in group B. During the follow-up period, stone recurrence was significantly less common in group A than in group B (13.6% vs 26.7%, P = 0.041). Multivariate Cox analysis showed that the PTCSL method (HR = 2.32, 95% confidence interval [CI] = 1.09–4.90, P = 0.028), bilateral biliary stricture (HR = 4.17, 95% CI = 1.73–10.03, P = 0.001), and stones located in segments I (HR = 7.75, 95% CI = 3.67–16.38, P = 0.000) were independent predictors of recurrence.

Conclusions

Compared with traditional PTCSL, one-step multichannel PTCSL was more efficient and effective in the treatment of bilateral hepatolithiasis.

     

Severe Lenke 1 and 2 adolescent idiopathic scoliosis had poorer perioperative outcome,higher complication rate,longer fusion and higher operative cost compared to non-severe scoliosis

Purpose

To compare the perioperative outcome and operative cost of posterior spinal fusion (PSF) surgery between severe and non-severe Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients.

Methods

A total of 509 AIS patients who underwent single-staged PSF between 2013 and 2020 were reviewed. Fifty-four severe scoliosis patients (Cobb angle ≥ 90°) were categorized into Gp1, and 455 non-severe scoliosis (Cobb angle < 90°) patients into Gp2. Propensity score matching (PSM) analysis using one-to-one nearest neighbor matching and match tolerance of 0.001 were performed. Outcome measures were operative time, intraoperative blood loss (IBL), allogeneic transfusion rate, perioperative complication, length of stay, fusion level, number of screws used, postoperative Cobb angle, correction rate (CR), side bending correction index (SBCI) and operative cost.

Results

From the PSM analysis, 35 patients from each group were matched. The operative time was 155.9 ± 41.4 and 130.0 ± 30.3 min for Gp1 and Gp2, respectively (p = 0.004). The IBL was 1349.2 ± 1019.0 and 781.9 ± 325.1 mLs for Gp1 and Gp2, respectively (p = 0.003). Fusion level (12.5 ± 0.8 vs. 11.2 ± 1.3, p < 0.001) and number of screws used (16.4 ± 1.6 vs. 14.6 ± 1.4, p < 0.001) were higher in Gp1. Four perioperative complications were observed in Gp1 compared to none in Gp2 (p < 0.039). Gp1 had larger postoperative Cobb angle (p < 0.001), lower CR (p = 0.005) and higher SBCI (p < 0.001). The operative cost was higher in Gp1 (p < 0.001).

Conclusions

Severe Lenke 1 and 2 AIS patients had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost than non-severe AIS.

     

The Obesity Paradox in the Trauma Patient: Normal May not Be Better

Objective

The obesity paradox is the association of increased survival for overweight and obese patients compared to normal and underweight patients, despite an increased risk of morbidity. The obesity paradox has been demonstrated in many disease states but has yet to be studied in trauma. The objective of this study is to elucidate the presence of the obesity paradox in trauma patients by evaluating the association between BMI and outcomes.

Methods

Using the 2014–2015 National Trauma Database (NTDB), adults were categorized by WHO BMI category. Logistic regression was used to assess the odds of mortality associated with each category, adjusting for statistically significant covariables. Length of stay (LOS), ICU LOS and ventilator days were also analyzed, adjusting for statistically significant covariables.

Results

A total of 415,807 patients were identified. Underweight patients had increased odds of mortality (OR 1.378, p < 0.001 95% CI 1.252–1.514), while being overweight had a protective effect (OR 0.916, p = 0.002 95% CI 0.867–0.968). Class I obesity was not associated with increased mortality compared to normal weight (OR 1.013, p = 0.707 95% CI 0.946–1.085). Class II and Class III obesity were associated with increased mortality risk (Class II OR 1.178, p = 0.001 95% CI 1.069–1.299; Class III OR 1.515, p < 0.001 95% CI 1.368–1.677). Hospital and ICU LOS increased with each successive increase in BMI category above normal weight. Obesity was associated with increased ventilator days; Class I obese patients had a 22% increase in ventilator days (IRR 1.217 95% CI 1.171–1.263), and Class III obese patients had a 54% increase (IRR 1.536 95% CI 1.450–1.627).

Conclusion

The obesity paradox exists in trauma patients. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance patient care.

Level of evidence

Level III, prognostic study

     

Mild and Moderate Traumatic Brain Injury and Gender-Based Critical Care Outcomes

Background

Traumatic brain injury (TBI) is a major contributor to death and complications. Previous studies have identified gender disparities among trauma patients. This study aims to examine the association between gender and outcomes in TBI patients.

Study design and methods

Review of our trauma registry: Patients were classified into groups according to their gender. Demographics extracted from the registry included age, injury severity score (ISS), Glasgow Coma Score (GCS), head abbreviated injury score (AIS), and the presence of an epidural hematoma (EDH). The primary outcome was mortality; secondary outcomes included ICU length of stay (ICU-LOS), craniotomy rate, ventilator-associated pneumonia (VAP), and readmission rates. Significance was defined as p < 0.05.

Results

Nine hundred and thirty-five patients with TBI were studied: 62.1% (n = 581) were male and 37.9% (n = 354) were female. There were no differences in GCS, ISS, and head AIS. Males were younger [53 (IQR 30–77) vs. 76 (IQR 49.25–84), p < 0.05] and were more likely to have an EDH (9.6% vs. 4.8%, p = 0.007). Males also had a longer median ICU-LOS [4 days (IQR 2–8) vs. 3 days (IQR 0–5), p < 0.05] and were significantly more likely to require a craniotomy (44.6% vs. 19.2%, p < 0.001). In addition, males were more likely to develop VAP (4.1% vs. 0.8%, p = 0.004). Predicted survival (79.2% vs. 72.9%) and actual mortality rates (4.5% vs. 4.5%) were similar in both genders (p > 0.05).

Conclusion

In the context of our study, male patients with TBI were significantly younger, were more likely to sustain an EDH, and were also more likely to require a craniotomy, but mortality rates between both genders were similar. The male gender was also associated with a significantly increased ICU-LOS and VAP.

     

Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program

Background

Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model.

Methods

The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge.

Results

A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985–0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686–3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478–0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500–0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h.

Conclusions

Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

     

Laparoscopic Major Hepatectomy: Do Not Underestimate the Impact of Specimen Extraction Site

Background

In laparoscopic major hepatectomy, analysis of outcomes according to specimen extraction site remains poorly described. The aim was to compare postoperative outcomes according to specimen extraction site.

Methods

From 2000 to 2017, all laparoscopic major hepatectomies were reviewed and postoperative outcomes were analyzed according to specimen extraction site: subcostal (Group 1), midline (Group 2), or suprapubic (Group 3) incision.

Results

Among 163 patients, 15 (9.2%) belonged to Group 1, 49 (30.1%) in Group 2, and 99 (60.7%) in Group 3. The proportion of right-sided, left-sided, or central hepatectomies, mortality, and overall and severe complications were comparable between groups. Group 1 had larger tumors (61 vs. 38 vs. 47 mm; P = 0.014), higher operative time (338 vs. 282 vs. 260 min; P < 0.008), higher adjacent organ resection rate (46.6 vs. 16.3 vs. 7.1%; P < 0.001), and tended to increase pulmonary complications (40.0 vs. 12.2 vs. 18.2%; P = 0.064). In Group 2, a previous midline incision scar was more frequently used for specimen extraction site (65.3 vs. 26.6 and 30.3%, Group 1 and 3; P < 0.001). Postoperative incisional hernia was observed in 16.4% (n = 23) and was more frequent in Group 2 (26.6 vs. 6.6% and 10.1%, Group 1 and Group 3; P = 0.030). Finally, Group 2 (HR 2.63, 95% CI 1.41–3.53; P = 0.032) was the only independent predictive factor of postoperative incisional hernia.

Conclusions

While using a previous incision makes sense, the increased risk of postoperative incisional hernia after midline incision promotes the suprapubic incision.

     

Trends in the Incidence,Treatment and Outcomes of Patients with Intrahepatic Cholangiocarcinoma in the USA: Facility Type is Associated with Margin Status,Use of Lymphadenectomy and Overall Survival

Introduction

Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types.

Methods

Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study.

Results

The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004–2009: 8.05 months vs. 2010–2015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of ≥6 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24–1.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04–1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001).

Conclusions

The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC.

     

High- versus low-viscosity cement vertebroplasty and kyphoplasty for osteoporotic vertebral compression fracture: a meta-analysis

Background

To compare high- versus low-viscosity bone cement on the clinical outcomes and complications in patients with Osteoporotic vertebral compression fractures (OVCFs) who underwent percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP).

Methods

PubMed, Embase, and the Cochrane Library were searched for papers published from inception up to February 2021 for potentially eligible studies comparing high- versus low-viscosity cement for PVP/PKP. The outcomes were the leakage rate, visual analog scale (VAS), and Oswestry Disability Index (ODI).

Results

Eight studies (558 patients; 279 in each group) were included. The meta-analysis showed that the leakage rate was lower with high-viscosity cement than with low-viscosity cement (OR = 0.23, 95%CI 0.14–0.39, P < 0.001; I² = 43.5%, P_{heterogeneity} = 0.088); similar results were observed specifically for the disk space, paravertebral space, and peripheral vein, but there were no differences regarding the epidural space and intraspinal space. The VAS was decreased more significantly with high-viscosity cement than with low-viscosity cement (WMD = − 0.21, 95%CI − 0.38, − 0.04, P = 0.015; I² = 0.0%, P_{heterogeneity} = 0.565). Regarding the ODI, there was no difference between high- and low-viscosity cement (WMD = − 0.88, 95%CI − 3.06, 1.29, P = 0.426; I² = 78.3%, P_{heterogeneity} < 0.001).

Conclusions

There were lower cement leakage rates in PVP/PKP with high-viscosity bone cement than low-viscosity bone cement. The two groups have similar results in ODI, but the VAS scores favor high-viscosity bone cement. Therefore, the administration of high-viscosity bone cement in PVP/ PKP could be a potential option for improving the complications of leakage in OVCFs, while the clinical efficacy of relieving pain is not certain.

     

Recurrence Patterns After Resection of Colorectal Liver Metastasis are Modified by Perioperative Systemic Chemotherapy

Background

This study investigated the impact of perioperative systemic chemotherapy on the recurrence rate and pattern following resection of colorectal liver metastases.

Methods

A retrospective cohort study was conducted in two centers. Rates and patterns of recurrence and overall survival (OS) were compared between patients treated with and without perioperative systemic chemotherapy. The clinical risk score (CRS) was used to stratify patients in low risk (CRS 0–2) and high risk (CRS 3–5) of recurrence.

Results

A total of 2020 patients were included, of whom 1442 (71%) received perioperative systemic chemotherapy. The median follow-up was 88 months, and 1289 patients (64%) developed a recurrence. The recurrence pattern was independent of chemotherapy in low-risk patients: intrahepatic recurrences (30% vs. 30%, p = 0.97) and extrahepatic recurrences (38% vs. 39%, p = 0.52). In high-risk patients, no difference in intrahepatic recurrences was found (48% vs. 50%, p = 0.59). However, a lower rate of extrahepatic recurrences (43% vs. 55%, p = 0.007) was observed with perioperative systemic chemotherapy, mainly due to a reduction in pulmonary recurrences (25% vs. 35%, p = 0.007). In competing risk analysis, the cumulative incidence of extrahepatic recurrence was significantly lower with perioperative systemic chemotherapy in high-risk patients only (5-year cumulative incidence 44% vs. 59%, p < 0.001). Perioperative chemotherapy was associated with improved OS in high-risk patients (adjusted HR 0.73, 95% CI 0.57–0.94, p = 0.02), but not in low-risk patients (adjusted HR 0.99, 95% CI 0.82–1.19, p = 0.90).

Conclusions

Perioperative systemic chemotherapy had no association with intrahepatic recurrence, but was associated with fewer pulmonary recurrences and superior OS in high-risk patients only.

     

Influence of posterior instrumented correction with pedicle screw dual rod systems on thoracic kyphosis in Lenke 1 and 2 curves: minimum 2 years follow-up

Purpose

Adolescent idiopathic scoliosis (AIS) often correspond with hypo thoracic kyphosis (TK) or even lordosis. The aim of this study was to analyze the influence of posterior instrumentation in thoracic AIS.

Methods

Analysis of prospectively collected AIS-data with structural thoracic curves (Lenke type 1 & 2), operated 2010–2019 with pedicle screw dual rod systems in one scoliosis center. Follow-up (FU) minimum 24 months. Coronal and sagittal angles measured based on standing long-cassette-X-rays: thoracic major (MC), proximal thoracic (PC) and lumbar curve (LC), TK, lumbar lordosis (LL). Statistical analysis: values as mean ± SD, differences by student’s t-test (significancy a = 0.05), Pearson’s correlation, sub-analysis with sagittal modifier (−, N, +).

Results

A total of 127 AIS could be identified (63% type 1, 37% type 2). Mean FU 32.2 ± 16.6 months, mean age 14 ± 1.5 years. Mean Correction of MC 73 ± 12%, PC 51 ± 17%, LC 69 ± 21% with a significantly better correction of PC in Lenke 2 curves(p < 0.05). On average, TK (FU-preop) decreased by -2.1 ± 12.1°(p < 0.05) in all AIS. Whereas TK in type 1 was unchanged (p = 0.9), TK significantly decreased by − 6.0 ± 12.7°(p < 0.05) in type 2. No significant difference in LL. TK in hypokyphotic cases increased by 9.5 ± 5.5°(p < 0.05), stayed almost unchanged (− 1.4 ± 9.1°,p = 0.2) in normokyphotic, decreased by − 17.2 ± 14.2°(p < 0.05) in hyperkyphotic cases. Only hypokyphotic cases had a moderately strong correlation between correction of LC (r = 0.6) and PC (r = − 0.4) (frontal plane) and change from pre- to postoperative TK (sagittal plane) (r = 0.6). No relevant correlations for normo- and hyperkyphotic AIS. Postoperative hypokyphosis was significantly more often in Lenke 2 (16.3% vs. 2.6%, p < 0.05). Rod diameter (5,5 mm versus 6 mm) had no significant influence.

Conclusion

Significant correction of hypo- and hyperkyphosis can be achieved with posterior spinal fusion (pedicle screw dual rod systems), whereas normokyphotic spines stay unchanged. However, Lenke 2 curves have a significantly higher risk for a postoperative thoracic hypokyphosis.

     

Risk Factors for and Prediction Model of Skip Metastasis to Lateral Lymph Nodes in Papillary Thyroid Carcinoma

Background

Cervical lymph node metastasis is a prognostic factor of papillary thyroid carcinoma (PTC). Skip metastasis (central lymph node negative and lateral lymph node positive) of PTC is not uncommon. This study aimed to retrospectively investigate the risk factors for skip metastasis in PTC and develop a prediction model for skip metastasis.

Methods

A total of 745 PTC patients underwent total thyroidectomy and central plus lateral lymph node dissection at the First Affiliated Hospital of Chongqing Medical University from January 2012 to December 2017. Clinicopathological characteristics were collected and analyzed. Univariate and multivariate analyses were performed to detect the risk factors for skip metastasis. A prediction model was established based on the results of multivariate analyses.

Results

The skip metastasis rate was 9.7% (72/745). Age > 55 years (OR 2.63, 95% CI 1.34–5.04, p = 0.004), tumor located in the upper portion (OR 4.15, 95% CI 2.30–7.63, p = 0.001), and unilaterality (OR 2.76, 95% CI 1.14–8.23, p = 0.040) were independent risk factors for skip metastasis. Clinically lymph node-negative (cN0) patients with tumor in the upper portion (24.6%, 43/175) had higher possibility of skip metastasis than those of clinically lateral lymph node-positive (cN1b) patients (5.9%, 10/169) (p = 0.001). The area under the receiver operating characteristic curve of prediction model was 0.734 and 0.740 in derivation group and validation group, respectively. However, skip metastasis was not associated with tumor-free survival rate of PTC patients (p = 0.274).

Conclusion

Age > 55 years, tumor located in the upper portion, and unilaterality may increase the risk of skip metastasis. We developed the first prediction model for skip metastasis based on clinicopathological parameters in PTC patients.

     

T1 pelvic angle is associated with rapid progression of hip arthrosis

Purpose

To evaluate the association between global spinal malalignment and rapid progression of hip arthrosis.

Methods

This was a retrospective, case–control study including 90 patients, contributing 90 hips, who underwent hemi- or total hip arthroplasty at our institution. For analysis, hips were classified into a rapid progression group, defined as ≥ 2 mm destruction of the femoral head or loss of the hip joint space within a 12-month period (n = 30), and a non-rapid progression group, defined by no observable hip disease progression over a period more than 12 months (n = 60). Logistic regression analysis identified factors that predicted rapid progression, with a receiver operating characteristic curve analysis used to confirm factors.

Results

Significant between-group differences were identified for the following parameters: pelvic tilt (P = 0.002, PT), sagittal vertical axis (P = 0.002, SVA), and T1 pelvic angle (P < 0.001, TPA). On multiple logistic regression, PT (P = 0.002), SVA (P = 0.002), and TPA (P < 0.001) were predictive of a rapid progression on hip arthrosis, with the area under the curve being greater for TPA than PT (P = 0.035).

Conclusion

Global spinal alignment is associated with rapid progression of hip arthrosis. TPA could assist in identifying patients at risk for rapid progression of hip arthrosis, allowing for time management.

     

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review

Introduction

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios.

Methods

A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24–48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

Results

A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001).

Conclusions

Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.

     

Cross-cultural adaptation and validation of the simplified chinese version of the fremantle back awareness questionnaire in patients with low back Pain

Purpose

The Fremantle back awareness questionnaire (FreBAQ) was recently developed as simple and quick tool to assess back-specific body perception in Low back pain (LBP) patients. The aim of the present study was to translate and cross-culturally adapt the Fremantle back awareness questionnaire (FreBAQ) into a Simplified Chinese version (FreBAQ-C), and evaluate the reliability and validity of the FreBAQ-C in patients with non-specific Chronic Low back pain (CLBP).

Methods

The FreBAQ was translated into Chinese according to established methods. Internal consistency was assessed according to Cronbach’s alpha. Test–retest reliability was estimated by Intraclass correlation coefficient (ICC). Construct validity was evaluated by correlations between the FreBAQ-C and Visual analogue scale (VAS), Roland-Morris disability questionnaire (RDQ), Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK) as well as Hospital anxiety and depression scale (HADS).

Results

A total of 105 participants (38 males and 67 females) were included in this study with the mean age of 54.1 ± 15.6 years, mean duration of LBP of 6.8 ± 4.6 years. The FreBAQ-C total scores were well distributed, with no floor or ceiling effects. Internal consistency was excellent (Cronbach’s alpha = 0.833). ICC of test–retest reliability was good (0.897, 95% confidence interval: 0.852–0.929). The limits of agreement (LOA) ranged from − 5.8 to 6.3. The Standard error of measurement (SEM) and Minimum detectable change (MDC) were 2.16 and 5.99. Construct validity was confirmed by significant correlation of The FreBAQ-C and VAS during motion (r = 0.274, p = 0.005) and rest (r = 0.243, p = 0.012), RDQ (r = 0.377, p < 0.001), PCS (r = 0.439, p < 0.001), and TSK(r = 0.311, p = 0.001).

Conclusions

The FreBAQ-C was demonstrated to have acceptable reliability and validity for patients with non-specific CLBP in Chinese mainland. It will allow evaluating body preception of the back in the Chinese population with CLBP.

     

Esophageal Position Affects Short-Term Outcomes After Minimally Invasive Esophagectomy: A Retrospective Multicenter Study

Background

Anatomical esophageal position may affect the short-term outcomes after minimally invasive esophagectomy (MIE). A previous single-institutional retrospective study suggested that the presence of a left-sided esophagus (LSE) made MIE more difficult and increased the incidence of postoperative complications.

Methods

The current study was a multicenter retrospective study of 303 patients with esophageal cancer who underwent MIE at six esophageal cancer high-volume centers in Kyushu, Japan, between April 2011 and August 2016. The patients were divided into the LSE (66 patients) and non-LSE groups (237 patients) based on the esophageal position on computed tomography images obtained with the patients in the supine position.

Results

Univariate analysis showed that patients with LSE were significantly older than those with non-LSE (69 ± 8 vs. 65 ± 9 years; P = 0.002), had a significantly greater incidence of cardiovascular comorbidity (65.2% vs. 47.7%; P = 0.013), and a significantly longer operating time (612 ± 112 vs. 579 ± 102 min; P = 0.025). Logistic regression analysis verified that LSE was an independent risk factor for the incidence of pneumonia (odds ratio 3.3, 95% confidence interval 1.254–8.695; P = 0.016).

Conclusions

The presence of a LSE can increase the procedural difficulty of MIE and the incidence of morbidity after MIE. Thus, careful attention must be paid to anatomical esophageal position before performing MIE.

     

Serum Magnesium Measurements After Parathyroidectomy for Primary Hyperparathyroidism: Should It be Routine?

Background

Parathyroidectomy is the treatment of choice in primary hyperparathyroidism (PHPT). Following surgery, significant changes in bone and mineral metabolism may follow, but routine magnesium monitoring is not standard practice. The occurrence of significant clinical events linked to hypomagnesaemia in 3 patients after parathyroidectomy led to our evaluation of magnesium levels after surgery for PHPT.

Methods

Serum magnesium levels before and after parathyroidectomy for PHPT were prospectively evaluated in a single centre over a year. The incidence and severity of hypomagnesaemia and its correlation with other biochemical variables were assessed.

Results

A total of 138 patients underwent parathyroidectomy for PHPT. Pre-operative and day 1 post-operative serum magnesium levels were available in 57/138 (41.3%) and 99/138 (71.7%) patients, respectively. Serum magnesium decreased significantly after surgery (mean ± SD of 0.85 ± 0.08 and 0.75 ± 0.11 mmol/L, respectively, p < 0.001). On the day after parathyroidectomy, 31/99 (31.3%) patients had hypomagnesaemia (<0.70 mmol/L); in 3 of whom it was severe (<0.50 mmol/L). Patients with hypomagnesaemia had lower pre-operative magnesium (mean ± SD of 0.78 ± 0.06 and 0.87 ± 0.07 mmol/L, p < 0.001), higher pre-operative calcium [median (IQR) of 2.83 (2.71–2.99) and 2.71 (2.63–2.80) mmol/L, p = 0.001] and higher post-operative calcium [median (IQR) of 2.41 (2.30–2.51) and 2.35 (2.28–2.43) mmol/L, p = 0.046] compared to those with normomagnesaemia. In addition, these patients demonstrated higher drop in calcium levels after surgery (0.44 ± 0.20 and 0.35 ± 0.18 mmol/L, p = 0.033). Magnesium levels after surgery correlated positively with pre-operative magnesium (r = 0.561, p < 0.001) and post-operative PTH (r = 0.210, p = 0.037) and negatively with pre-operative adjusted calcium (r = − 0.389, p < 0.001).

Conclusions

Serum magnesium decreased significantly following parathyroidectomy for PHPT and nearly a third of patients developed post-operative, mostly mild hypomagnesaemia. Whilst routine serum magnesium measurements could facilitate prompt recognition and treatment of this electrolyte disturbance, further research needs to establish the clinical importance of mild hypomagnesaemia in these clinical settings and, if indicated, to devise optimal treatment strategies.

     

Digital measurement and correlation analysis of coronal and sagittal anatomic parameters in the radiographs of adolescent patients with idiopathic scoliosis

Objective

To use digital software to measure the morphologic and anatomic parameters of adolescent idiopathic scoliosis (AIS). Differences and correlations among different parameters were compared to provide an anatomic basis for the selection of treatment methods and preoperative evaluation of AIS.

Methods

Spinal radiographs were taken from 300 boys and girls (age, 10–18 years) suffering from idiopathic scoliosis in four grade-A hospitals in Inner Mongolia. After screening, 120 cases with complete imaging data were assessed. Imaging data were transferred to a work station (Dr Wise™). The anatomic indices of the Cobb Angle, CVA, AVT, TS, CA, CPT, CSI, FPT, CCA, TK, LL, SS, PT, and PI were measured.

Results

There were significant differences in AVT between different grades and types of scoliosis (F = 34.079, P = 0.000; χ² = 23.379, P = 0.000). AVT was a protective factor, and the smaller the AVT, the less severe was the scoliosis. Compared with adolescents with mild or moderate scoliosis, the Cobb angle of adolescents with severe scoliosis was negatively correlated with CCA, LL, and SS (r =  − 0.641, p < 0.05; r =  − 0.695, p < 0.01; r =  − 0.814, p < 0.01).

Conclusions

Some of the anatomic parameters in the coronal and sagittal planes of adolescents with idiopathic scoliosis were significantly different according to the severity and type of scoliosis. Significant correlations were found between more anatomic indices in adolescents with severe scoliosis than in adolescents suffering from mild or moderate scoliosis.

     

Value of MRI in assessing back pain after thoracolumbar osteoporotic vertebral compression fractures and discussion on the underlying mechanisms by tissue biopsy

Purpose

The specific radiological feature of osteoporotic vertebral compression fractures (OVCFs) is bone marrow oedema (BME) on magnetic resonance imaging (MRI). However, the relationship between BME and back pain (BP) is unclear. We investigated the value of MRI in assessing BP and discussed the relevant mechanisms by tissue biopsy.

Methods

One hundred nineteen patients with thoracolumbar OVCFs were included in this study. We divided all patients into two groups: the low-oedema group (BME ≤ 75%) and the high-oedema group (BME > 75%). To reduce the error generated in the acute phase of fracture, we separately analysed patients in phases I (within one month) and II (more than one month). We compared the differences between the groups using the Mann–Whitney U test and investigated the correlations using Spearman’s correlation test.

Results

The degree of BP was significantly correlated with BME (p < 0.001; p < 0.001) and fibrous tissue content (p = 0.006; p = 0.035) in both phases. Further, the fibrous tissue content in the low-oedema group (12.49 ± 7.37%; 15.25 ± 13.28%) was significantly lower than that in the high-oedema group (25.68 ± 20.39%, p = 0.014; 23.92 ± 14.61%, p = 0.022) in both phases. The lamellar bone content was significantly correlated with BP (p = 0.021) in phase II.

Conclusions

BME signals on MRI can accurately predict the degree of BP, and the main mechanisms are related to the stimulation of fibrous tissue.

     

Risk factors for thirty-day morbidity and mortality after spinal trauma

Background

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined.

Methods

Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed.

Results

The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay.

Conclusion

Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

     

Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery

Objectives

To evaluate enhanced recovery after surgery (ERAS) protocols in emergency abdominal surgery.

Methods

The electronic data sources were explored to capture all studies that evaluated the impact of ERAS protocols in patients who underwent emergency abdominal surgery. The quality of randomised and non-randomised studies was evaluated by the Cochrane tool and the Newcastle–Ottawa scale, respectively. Random or fixed effects modelling were utilised as indicated.

Results

Six comparative studies, enrolling 1334 patients, were eligible. ERAS protocols resulted in shorter post-operative time to first flatus (mean difference: −1.40, P < 0.00001), time to first defecation (mean difference: −1.21, P = 0.02), time to first oral liquid diet (mean difference: −2.30, P < 0.00001), time to first oral solid diet (mean difference: −2.40, P < 0.00001) and length of hospital stay (mean difference: −3.09, −2.80, P < 0.00001). ERAS protocols also resulted in lower risks of total complications (odds ratio: 0.50, P < 0.00001), major complications (odds ratio: 0.60, P = 0.0008), pulmonary complications (odds ratio: 0.38, P = 0.0003), paralytic ileus (odds ratio: 0.53, 0.88, P = 0.01) and surgical site infection (odds ratio: 0.39, P = 0.0001). Both ERAS and non-ERAS protocols resulted in similar risk of 30-day mortality (risk difference: −0.00, P = 0.94), need for re-admission (risk difference: −0.01, P = 0.50) and need for re-operation (odds ratio: 0.83, P = 0.50).

Conclusions

Although ERAS protocols are commonly used in elective settings, they are associated with favourable outcomes in emergency settings as indicated by reduced post-operative complications, accelerated recovery of bowel function and shorter post-operative hospital stay without increasing need for re-admission or re-operation. There should be an effort to incorporate ERAS protocols into emergency abdominal surgery settings.