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.

     

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.

     

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.

     

Prolonged Hospital Stay After Parathyroidectomy for Secondary Hyperparathyroidism

Background  Protracted hypocalcemia is the most common complication after parathyroidectomy for secondary hyperparathyroidism. Several parameters have been identified to predict the degree of postoperative hypocalcemia. The purpose of this study was to determine whether there were any factors associated with prolonged hospitalization in these patients. Methods  A total of 81 consecutive patients with end-stage renal disease and advanced secondary hyperparathyroidism who underwent parathyroidectomy between January 2004 and December 2006 were studied. The postoperative calcium infusion protocol and discharge criteria were standardized. Clinical variables were compared between patients with a shorter or longer postoperative stay. Results  The mean postoperative hospital stay was 5.6 days. Preoperative alkaline phosphatase levels were significantly higher in patients with a longer stay (p = 0.035). In a linear regression model, the postoperative length of stay was moderately but significantly correlated with preoperative alkaline phosphatase levels (R ² = 0.254; p < 0.001). Receiver operating characteristic analysis showed a significant area under the curve (0.678; 95% confidence interval 0.550–0.805; p = 0.014). With a cutoff of preoperative alkaline phosphatase levels at 200 IU/L, the sensitivity was 0.57 and the specificity was 0.59 for predicting a prolonged stay. Conclusions  A high preoperative alkaline phosphatase level is significantly associated with prolonged hospital stay in patients undergoing parathyroidectomy for secondary hyperparathyroidism.     

ISSLS PRIZE in Clinical Science 2022: Epidemiology,risk factors and clinical impact of juvenile Modic changes in paediatric patients with low back pain

Purpose

It’s a long-held belief that Modic changes (MC) occur only in adults, with advanced age, and are highly associated with pain and adverse outcomes. The following study addressed the epidemiology, risk factors and clinical relevance of MC in young paediatric patients.

Methods

Two hundred and seven consecutive patients with no history of deformities, neoplasms, trauma, or infections were included in this ambispective study. MRIs were utilized to assess MCs and types, and other degenerative disc/endplate abnormalities. Subject demographics, duration of symptoms, clinic visits, conservative management (physical therapy, NSAIDs, opioids, injections) and surgery were noted.

Results

The mean age was 16.5 years old (46.9% males), 14% had MCs and they occurred throughout the spine. Subject baseline demographics were similar between MCs and non-MCs patients (p > 0.05). Modic type 2 (50%) was the most common type (type 1:27.1%; type 3:18.8%; mixed:4.7%). Multivariate analyses noted that endplate damage (OR: 11.36), disc degeneration (OR: 5.81), disc space narrowing (OR: 5.77), Schmorl’s nodes (OR: 4.30) and spondylolisthesis (OR: 3.55) to be significantly associated with MCs (p < 0.05). No significant differences in conservative management were noted between Modic and non-MCs patients (p > 0.05). Among surgery patients (n = 44), 21% also had MCs (p = 0.134). Symptom-duration was significantly greater in MC patients (p = 0.049).

Conclusion

Contrary to traditional dogma, robust evidence now exists noting that MCs and their types can develop in children. Our findings give credence to the “Juvenile” variant of MCs, whereby its implications throughout the lifespan need to be assessed. Juvenile MCs have prolonged symptoms and related to specific structural spine phenotypes.

     

Percutaneous pedicle screw fixation without arthrodesis of 368 thoracolumbar fractures: long-term clinical and radiological outcomes in a single institution

Purpose

Traumatic thoracolumbar (TL) fractures are the most common vertebral fractures. Although a consensus on the preferred treatment is missing, percutaneous pedicle screw fixation (PPSF) has been progressively accepted as treatment option, since it is related to lower soft tissues surgical-injury and perioperative complications rate. This study aims to evaluate the long-term clinical–radiological outcomes after PPSF for TL fractures at a single tertiary academic hospital.

Methods

This is a retrospective cohort study. Back pain was obtained at preoperative, postoperative and final follow-up using Visual Analog Scale. Patient-reported outcomes, the Oswestry Disability Index and the 36-Item Short Form, were obtained to asses disability during follow-up. Radiological measures included Cobb angle, mid-sagittal index, sagittal index (SI) and vertebral body height loss. A multivariate regression analysis on preoperative radiological features was performed to investigate independent risk factors for implant failure.

Results

A total of 296 patients with 368 TL fractures met inclusion criteria. Mean follow-up was 124.3 months. The clinical and radiological parameters significantly improved from preoperative to last follow-up measurements. The multivariate analysis showed that Cobb angle (OR = 1.3, p < 0.001), SI (OR = 1.5, p < 0.001) and number of fractures (OR = 1.1, p = 0.05), were independent risk factors for implant failure. The overall complication rate was 5.1%, while the reoperation rate for implant failure was 3.4%.

Conclusions

In our case series, PPSF for TL injuries demonstrated good long-term clinical-radiological outcomes, along with low complication and reoperation rates. Accordingly, PPSF could be considered as a valuable treatment option for neurologically intact patients with TL fractures. Additionally, in this cohort, number of fractures ≥ 2, Cobb angle ≥ 15° and sagittal index ≥ 21° were independent risk factors for implant failure.

     

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.

     

Is 3D-printed prosthesis stable and economic enough for anterior spinal column reconstruction after spinal tumor resection? A retrospective comparative study between 3D-printed off-the-shelf prosthesis and titanium mesh cage

Object

To investigate the stability and cost-effectiveness of the three-dimensional-printed (3DP) off-the-shelf (OTS) prosthesis in the reconstruction of the anterior column of the thoracic/lumbar spine after tumor resection.

Methods

Thirty-five patients (26 with primary malignant tumors and nine with metastatic malignant tumors) who underwent tumor resection and anterior column reconstruction between January 2014 and January 2019 were included in a single institute. Patients were divided into the 3DP OTS prosthesis (3DP) group (n = 14) and the titanium mesh cage (TMC) group (n = 21) by the type of implant. The operation time, intraoperative blood loss, hospital stay, history of radiotherapy, surgical level and total cost were collected and compared between the two groups. Mechanical complications and radiological parameters including mean vertebral height, subsidence, fixation failure(nonunion, migration, screw loosening, rod breakage) rate were recorded at preoperation, 1 week, 3 months, 6 months, 12 months after surgery then at 1 year interval or stop until the end of survival. The follow-up patients were also sent with short form-36 to assess their health-related quality of life (HRQoL) and questions about the current condition of their disease.

Results

The mean overall follow-up was 24.6 months. Of the 35 patients involved, six patients died and six were lost to follow-up. The differences between the two groups in operative time, intraoperative blood loss, and hospital stay were not statistically significant (p > 0.05). The differences in fixation failure and the subsidence rate between the two groups were not statistical significant (p > 0.05). The difference of subsidence rate between the cases with and without osteoporosis, cases with and without radiotherapy was statistically significant within each group (p < 0.05). However, the difference of subsidence rate between the surgical level above or below T10 was not statistically significant (p > 0.05). The response rate of the questionnaire among the survived patients was 100% (23/23 patients). The results of the Short Form- (SF-)36 between the two groups were similar (p > 0.05). The total cost was higher in the 3DP group (p < 0.05) with its higher graft cost (p < 0.05), but the differences in internal fixation cost and other cost were not statistically significant between groups (p > 0.05).

Conclusion

Compared to TMC, the 3DP OTS prosthesis achieved similar clinical and radiological results in spinal anterior spinal column reconstruction of thoracic/lumbar spinal tumor resection. However, the 3DP OTS prosthesis was more expansive than TMC.

     

Posterolateral full-endoscopic debridement and irrigation is effective in treating thoraco-lumbar pyogenic spondylodiscitis,except in cases with large abscess cavities

Purpose

To determine the efficacy and poor prognostic factors of posterolateral full-endoscopic debridement and irrigation (PEDI) surgery for thoraco-lumbar pyogenic spondylodiscitis.

Methods

We included 64 patients (46 men, 18 women; average age: 63.7 years) with thoracic/lumbar pyogenic spondylodiscitis who had undergone PEDI treatment and were followed up for more than 2 years. Clinical outcomes after PEDI surgery were retrospectively investigated to analyze the incidence and risk factors for prolonged and recurrent infection.

Results

Of 64 patients, 53 (82.8%) were cured of infection after PEDI surgery, and nine (17.2%) had prolonged or recurrent infection. Multivariate analysis demonstrated that significant risk factors for poor prognosis included a large intervertebral abscess cavity (P = 0.02) and multilevel intervertebral infections (P < 0.05).

Conclusion

PEDI treatment is an effective, minimally invasive procedure for pyogenic spondylodiscitis. However, a large intervertebral abscess space could cause instability at the infected spinal column, leading to prolonged or recurrent infection after PEDI. In cases with a large abscess cavity with or without vertebral bone destruction, endoscopic drainage alone may have a poor prognosis, and spinal fixation surgery could be considered.

     

Surgical Complications in Children with CDH: A Multivariate Analysis

Introduction

Several medical and surgical improvements in the treatment of congenital diaphragmatic hernia (CDH) patients have led to a higher survival rate. However, some of these improvements also lead to an increased morbidity rate. This study aims to determine the contribution different medical and surgical treatments have had on the development of surgical complications.

Method

All CDH patients treated in a single centre between 2000 and 2015 were retrospectively evaluated. Multivariate logistic regression was used to estimate the independent effects of several treatment options that could influence the surgical outcome by adjustment for multiple risk factors.

Results

Sixty of the 197 surgically repaired CDH patients had surgical complications. There were more haemorrhagic complications in the ECMO compared to non-ECMO group (27% vs. 2%, p < 0.001). The use of inhaled nitric oxide was also significantly related to haemorrhage (OR = 13.0 (95% CI 1.1–159)). After adjustment for other risk factors, chylothorax was neither significantly associated with ECMO treatment (OR = 1.6 (95% CI 0.5–5.2) nor with patch repair (OR = 2.1: 95% CI 0.7–6.1). A recurrence occurred more often in patients with pulmonary hypertension (OR = 10.0 (95% CI 1.5–65.8) and after treatment with an abdominal patch (OR = 11.3: 95% CI 1.5–84.4).

Conclusion

ECMO treatment and the inhalation of nitric oxide are used in the most severe CDH patients but are associated with a higher risk on surgical haemorrhage. The recurrence rate is associated with both the use of an abdominal patch and the presence of pulmonary hypertension, regardless of medical treatment.

     

Anterior thoracolumbar column reconstruction with the vertebral body stent—safety and efficacy

Purpose

The aim of this study was to assess safety and efficacy of vertebral body stenting (VBS) by analyzing (1) radiographic outcome, (2) clinical outcome, and (3) perioperative complications in patients with vertebral compression fractures treated with VBS at minimum 6-month follow-up.

Methods

In this retrospective cohort study, 78 patients (61 ± 14 [21–90] years; 67% female) who have received a vertebral body stent due to a traumatic, osteoporotic or metastatic thoracolumbar compression fracture at our hospital between 2012 and 2020 were included. Median follow-up was 0.9 years with a minimum follow-up of 6 months. Radiographic and clinical outcome was analyzed directly, 6 weeks, 12 weeks, 6 months postoperatively, and at last follow-up.

Results

Anterior vertebral body height of all patients improved significantly by mean 6.2 ± 4.8 mm directly postoperatively (p < 0.0001) and remained at 4.3 ± 5.1 mm at last follow-up compared to preoperatively (p < 0.0001). The fracture kyphosis angle of all patients improved significantly by mean 5.8 ± 6.9 degrees directly postoperatively (p < 0.0001) and remained at mean 4.9 ± 6.9 degrees at last follow-up compared to preoperatively (p < 0.0001). The segmental kyphosis angle of all patients improved significantly by mean 7.1 ± 7.6 degrees directly postoperatively (p < 0.0001) and remained at mean 2.8 ± 7.8 degrees at last follow-up compared to preoperatively (p = 0.03). Back pain was ameliorated from a preoperative median Numeric Rating Scale value of 6.5 to 3.0 directly postoperatively and further bettered to 1.0 six months postoperatively (p = 0.0001). Revision surgery was required in one patient after 0.4 years.

Conclusion

Vertebral body stenting is a safe and effective treatment option for osteoporotic, traumatic and metastatic compression fractures.

     

Open Abdomen in Obese Patients: Pay Attention! New Evidences from IROA,the International Register of Open Abdomen

Background

Open abdomen is the cornerstone of damage control strategies in acute care and trauma surgery. The role of BMI has not been well investigated. The aim of the study was to assess the role of BMI in determining outcomes after open abdomen.

Methods

This is an analysis of patients recorded into the International Register of Open Abdomen; patients were classified in two groups according to BMI using a cutoff of 30 kg/m². The primary outcome was in-hospital mortality; secondary outcomes were primary fascia closure rate, length of treatment, complication rate, entero-atmospheric fistula rate and length of ICU stay.

Results

A total of 591 patients were enrolled from 57 centers, and obese patients were 127 (21.5%). There was no difference in mortality between the two groups; complications developed during the open treatment were higher in obese patients (63.8% vs. 53.4%, p = 0.038) while post-closure complications rate was similar. Obese patients had a significantly longer duration of the open treatment (9.1 ± 11.5 days vs. 6.3 ± 7.5 days; p = 0,002) and lower primary fascia closure rate (75.5% vs. 89.5%; p < 0,001). No differences in fistula rate were found. There was a linear correlation between the duration of open abdomen and the BMI (Pearson’s linear correlation coefficient = 0,201; p < 0,001).

Conclusions

Open abdomen in obese patients seems to be safe as in non-obese patients with similar mortality; however, in obese patients the length of open abdomen is significantly higher with higher complication rate, longer ICU length of stay and lower primary fascia closure rate.

Trial registration number

ClinicalTrials.gov, Identifier: NCT02382770.

     

Correlation between kidney function and mortality in pyogenic spondylodiscitis: the glomerular filtration rate (GFR) as new predictive parameter?

Objective

Pyogenic spondylodiscitis is a severe medical condition, often requiring surgical intervention. Numerous risk factors are known, such as obesity, neurological impairment and old age. In-hospital mortality remains high, therefore other factors may be contributing to the increased mortality. To evaluate kidney function as a risk factor for increased morbidity of pyogenic spondylodiscitis, the glomerular filtration rate (GFR) was correlated with the patients' clinical course.

Materials and methods

We retrospectively reviewed the cases of 366 patients and 255 were included for analysis. Clinical, laboratory and surgical data were recorded with a minimum follow-up of three months. For clinical outcome measurement, mortality, length of stay and perioperative complications were analysed.

Results

The study included 255 patients (173 men, 82 women; mean age 66.3 years). Patients with a GFR < 59 mL/min spent an average of 5 days longer in the hospital than those with a GFR ≥ 60 mL/min (p = 0.071). The mortality rate increased significantly with a decrease in GFR: A GFR of 30–59 mL/min had a mortality rate of 17.6%, whereas a GFR of < 29 mL/min had one of 30.4% (p = 0.003). Patients with impaired GFR showed an increased rate of postoperative complications (OR 4.7 p = 0.002) and higher rate of intensive care unit (ICU) stay (OR 8.7 p =  < 0.001).

Discussion

Preoperative GFR values showed a significant correlation with in-hospital mortality in patients with spondylodiscitis, when graded according to the KDIGO stages. Furthermore, a GFR of < 29 ml/mL contributes to a longer ICU stay, postoperative complications and a longer total hospital stay. Therefore, the preoperative GFR could be a marker of kidney function and as a valuable predictive risk factor regarding the clinical in-hospital course of patients suffering from pyogenic spondylodiscitis.

     

Is unilateral pedicle screw fixation as effective as bilateral pedicle screw fixation in transforaminal lumbar interbody fusion: a meta-analysis of randomized controlled trials

Purpose

This meta-analysis aimed to investigate whether unilateral pedicle screw fixation (UPSF) is comparable to bilateral pedicle screw fixation (BPSF) in transforaminal lumbar interbody fusion (TLIF) for lumbar degenerative diseases.

Methods

Up to September 2022, established electronic literature databases including PubMed, Web of Science, EMBASE, and the Cochrane Library were systematically searched. Randomized controlled trials (RCTs) published in English that compared the efficacy of UPSF versus BPSF in TLIF were included. The methodological quality was evaluated, relevant data was extracted, and suitable meta-analysis was carried out. Data of fusion rate, complications, cage migration, visual analog scale (VAS), and Oswestry Disability Index (ODI), total blood loss (TBL), operation time, and hospital stay were extracted and analyzed. Pooled mean differences and risk ratio (RR) along with 95% confidence intervals (95% CI) were calculated for the results.

Results

Ten RCTs including 614 patients (UPSF = 294, BPSF = 320) were included in our meta-analysis. There were no significant differences in terms of fusion rate, VAS (VAS-BP and VAS-LP), ODI, complications, or hospital stay between UPSF and BPSF groups (P > 0.05, respectively). The UPSF group clearly had the advantage of less blood loss (SMD = −2.99, 95% CI [−4.54, −1.45], P = 0.0001) and operation time (SMD = −2.05, 95% CI [−3.10, −1.00], P = 0.0001). However, UPSF increased cage migration more than BPSF (10.7% vs 4.8%, RR = 2.23, 95% CI [1.07, 4.65],  P = 0.03).

Conclusion

According to the findings of this meta-analysis, UPSF is just as effective as BPSF in TLIF and may reduce blood loss and operation time. Nevertheless, UPSF may result in more cage migration than BPSF.

     

A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data,surgical outcome and cost-effectiveness

Purpose

Laparoscopic techniques have been used and refined in hernia surgery for several years. The aim of this study was to compare an established method such as laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) with ventral Transabdominal Preperitoneal Patch Plasty (ventral-TAPP) in abdominal wall hernia repair.

Methods

Patient-related data of 180 laparoscopic ventral hernia repairs between June 2014 and August 2020 were extracted from our prospectively maintained database. Of these patients, 34 underwent ventral-TAPP and 146 lap. IPOM. After excluding hernias with a defect size > 5 cm and obtaining balanced groups with propensity-score matching, a comparative analysis was performed in terms perioperative data, surgical outcomes and cost-effectiveness.

Results

Propensity-score matching suggested 27 patients in each of the two cohorts. The statistical evaluation showed that intake of opiates was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.001). The Visual Analogue Scale (VAS) score after lap. IPOM repair was significantly higher at movement (p = 0.008) and at rest (p = 0.023). Also, maximum subjective pain during hospital stay was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.004). No hernia recurrence was detected in either group. The material costs of ventral-TAPP procedure (34.37 ± 0.47 €) were significantly lower than those of the lap. IPOM group (742.57 ± 128.44 € p = 0.001). The mean operation time was 65.19 ± 26.43 min in the lap. IPOM group and 58.65 ± 18.43 min in the ventral-TAPP cohort. Additionally, the length of hospital stay in the lap. IPOM cohort was significantly longer (p = 0.043).

Conclusion

Ventral-TAPP procedures represent an alternative technique to lap. IPOM repair to reduce the risk of complications related to intra-peritoneal position of mesh and fixating devices. In addition, our study showed that postoperative pain level, material costs and hospital stay of the ventral-TAPP cohort are significantly lower compared to lap. IPOM patients.

     

Increased Morbidity and Mortality of Emergency Laparotomy in Elderly Patients

Background

There is an increasing incidence of elderly patients requiring emergency laparotomy. Our study compares the outcomes of elderly patients undergoing emergency laparotomy against the outcomes of non-elderly patients.

Methodology

Patients who underwent emergency laparotomy between 2015 and 2017 from the National University Hospital, Singapore, were included. Apart from demographic data, indication of surgery and surgical procedure performed were collected. Prospectively collected nutritional scores were evaluated. Outcome measures included duration of surgery, length of ICU and total hospital stay, post-operative complications, and mortality indices. We performed multivariate Cox regression analysis to determine the contribution of various risk factors towards overall survival following emergency laparotomy.

Results

A total of 170 emergency laparotomies were performed. Compared to non-elderly patients, elderly patients had a significantly longer mean stay in hospital (31.5 vs. 18.6 days, p = 0.006) and mean stay in ICU (13.1 vs. 5.3 days, p = 0.003). More elderly patients suffered from post-laparotomy complications compared with non-elderly patients (65.8% vs. 37.4%, p < 0.001). 30-day mortality (31.5% vs. 8.8%, p = 0.019) and 1-year mortality (27.9% vs. 14.3%, p = 0.023) were higher in elderly patients compared with non-elderly patients. Interestingly, there was no statistically significant difference between elderly and non-elderly groups in both the global 3-MinNS as well as the global SGA nutritional scores. ASA status (HR 2.61, 95% CI 1.05–6.45, p = 0.038) was an independent risk factor for decreased survival following emergency laparotomy. Notably, while age ≥ 65 demonstrated a significant correlation with survival on univariate analysis (HR 1.03 (1.01–1.05), p = 0.003), this effect was lost following multivariate regression (HR 1.01 (0.453–2.23), p = 0.989).

Conclusion

Elderly patients suffer worse morbidity and mortality following emergency laparotomy. This is likely contributed by comorbidities resulting in higher ASA status.

     

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

     

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.

     

Effects of isoflavones on bone turnover markers in peritoneal dialysis patients: a randomized controlled trial

Purpose

The aim of this study was to investigate the effects of soy isoflavones on serum markers of bone formation and resorption in peritoneal dialysis (PD) patients.

Methods

In this randomized, double-blind, placebo-controlled trial, 40 PD patients were randomly assigned to either the soy isoflavone or the placebo group. The patients in the soy isoflavone group received 100 mg soy isoflavones daily for 8 weeks, whereas the placebo group received corresponding placebos. At baseline and the end of the 8th week, 7 ml of blood was obtained from each patient after a 12- to 14-h fast and serum concentrations of bone formation markers (osteocalcin and bone alkaline phosphatase), bone resorption markers [N-telopeptide and receptor activator of nuclear factor kappa B ligand (RANKL)], and osteoprotegerin as an inhibitor of bone resorption were measured.

Results

Serum N-telopeptide concentration decreased significantly up to 27% in the soy isoflavone group at the end of week 8 compared to baseline (P?=?0.003). Also, serum RANKL concentration reduced significantly up to 17% in the soy isoflavone group at the end of week 8 compared to baseline (P?=?0.03). These bone resorption markers did not significantly change in the placebo group during the study. There were no significant differences between the two groups in mean changes of serum osteocalcin, bone alkaline phosphatase, and osteoprotegerin.

Conclusion

This study indicates that daily administration of 100 mg soy isoflavone supplement to PD patients reduces serum N-telopeptide and RANKL which are two bone resorption markers.

ClinicalTrials.gov

NCT03773029, 2018.

     

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.