Sutureless re-anastomosis by laparoscopy versus microsurgical re-anastomosis by laparotomy for sterilization reversal: a matched cohort study

BACKGROUND: Sutureless re-anastomosis per laparoscopy is an alternative for microsurgical re-anastomosis by laparotomy in the treatment of sterilized women with renewed child wish. Our aim was to compare pregnancy rates after both surgical techniques. METHODS: We performed a retrospective cohort study in which consecutive women who underwent sutureless re-anastomosis per laparoscopy were compared to women who underwent microsurgical re-anastomosis by laparotomy. Both procedures were performed in neighbouring hospitals in Northern-Brabant, The Netherlands, and women were matched for age. The primary outcome was time to ongoing pregnancy. RESULTS: Overall, we included 41 women who had sutureless re-anastomosis by laparoscopy, and 41 age-matched women who underwent microsurgical re-anastomosis by laparotomy. The number of women who conceived was 20 (15 ongoing pregnancies) in the sutureless laparoscopic group versus 26 (24 ongoing pregnancies) in the laparotomic group, a difference due to a longer follow-up period in the laparotomic group. Time to ongoing pregnancy was comparable in both groups (P=0.46), with 3 year cumulative ongoing pregnancy rates of 45 and 52% respectively. After adjustment for other prognostic factors, the fecundity rate ratio was 0.97 (95% CI 0.26-3.6), indicating a similar performance of the two techniques. CONCLUSION: The simplified stitchless laparoscopic procedure for reversal of tubal sterilization with the use of a tubal splint, clip fixation of the muscularis and fibrin glue resulted in a promising pregnancy rate, which was similar to the pregnancy rate obtained with the microsurgical re-anastomosis per laparotomy.     

Self-Expanding Prostheses for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic valve replacement in patients who are considered high surgical risk or inoperable due to advanced age and comorbidities. Randomized trial and registry data have demonstrated the safety and efficacy of TAVR in such patients. Currently available transcatheter heart valves (THVs) employ either balloon-expandable or self-expanding designs, and several new designs have shown promising early results. Differences in valve design may offer specific advantages for accurate deployment and minimizing complications. This article reviews several designs of self-expanding THVs that are currently available or have undergone successful implantation in humans. Additional studies are required to compare the relative performance of these devices.     

Direct comparison of rapid deployment versus sutureless aortic valve replacement: a meta-analysis

BackgroundThis meta-analysis was conducted to compare the procedural and early outcomes of aortic valve replacement (AVR) using rapid deployment valve (RD group) versus sutureless valve (SU group).MethodsA literature search of 5 online databases was conducted. The primary outcomes were mean transvalvular pressure gradient (MPG) after AVR, the incidence of paravalvular leak (PVL) and the need for a permanent pacemaker implantation (PPI). The secondary outcomes included aortic cross-clamp (ACC) and cardiopulmonary bypass (CPB) times, early mortality and other postoperative complications, such as atrial fibrillation, bleeding reoperation and stroke.ResultsEight articles were included, and all outcomes except MPG after AVR in matched valve sizes were extracted from 7 studies (RD group =842 patients and SU group =1,386 patients). The pooled analysis demonstrated a lower MPG in the RD group than in the SU group, with mean difference (MD) of 2.64 mmHg. The pooled risk ratios of any PVL and grade ≥2 (or moderate) PVL were not significantly different between the groups; however, the incidence of PPI was significantly lower in the RD group than in the SU group, with a risk ratio of 0.69. The pooled analyses showed that the ACC and CPB times were significantly longer in the RD group than in the SU group, with weighted MDs of 8.74 (P<0.001) and 9.94 (P<0.001) minutes, respectively. The risks of early mortality and other postoperative complications were not significantly different between the groups.ConclusionsAVR using RD valve was associated with better valve hemodynamics in terms of the MPG than AVR using SU valve, and better outcomes were observed in the RD group regarding PPI. Procedural times were longer in AVR using RD valve than SU valve. Early clinical outcomes showed no difference between RD and SU valve.     

An Analysis of 114 Consecutive Patients with Complete One-Year Follow-Up

This study assesses the clinical and electrode complications associated with the use of the epicardial screw-on electrode technique for permanent ventricular pacing. The records of 114 consecutive patients who received screw-on epicardial electrodes were analyzed in-hospital and at one year following implantation. We compared two techniques of implanting the screw-on electrode: 72 transmediastinal (TM) and 42 subxiphoid (SX) procedures. Baseline clinical inequalities were not apparent between the SX and TM patients. There was one operative death in the SX series and none among the TM patients. Total hospital mortality was 4% in the SX group and 2% in the TM group. In-hospital morbidity in the SX series (13/72-18%) was less than the TM group (14/42-33%), largely due to pleural entry and necessity for more frequent chest tube placement in TM patients. Electrode complications were low in both groups (3% in-hospital and 3% late; total 6/114, or 5%). Morbidity and mortality of these approaches to direct myocardial pacing remain noticeably higher than reported results of some transvenous series. Excellent electrode stability can be attained using the screw-on electrode, however, and the SX approach offers lower hospital morbidity than the TM method.     

Scleral implants: An historical perspective

Scleral implants are made of absorbable or nonabsorbable materials. One category of absorbable materials consists of donor tissue, either autogenous (fascia lata, plantaris gracilis tendon) or from cadavers (dura mater, sclera, fascia lata). A second category includes gelatin, reconstituted collagen, absorbable gut, fibrin, blood plasma, air, and sodium hyaluronate; of these, specially prepared gelatin seems to be the most useful. Nonabsorbable implant materials have proven more practical than absorbable implants. Solid silicone rubber is currently the most popular scleral implant material. It is soft, easy to handle, and well tolerated. Expandable implants, either temporary or permanent, are used in the form of a silicone balloon filled with liquid. Silicone sponge, also widely used, has the advantage of great softness. However, hydrogels seem to be the ideal scleral implants. The only one commercially available is Refojo's MAI implant. It is very soft and is not damaged by sutures, has a smooth surface, is molded in several sizes and shapes, and has small pores that microorganisms cannot penetrate. When saturated with a water-soluble antibiotic before implantation, this implant releases the antibiotic postoperatively for a longer time than any other implant material. Finally, surgical adhesives are useful when the sclera is too thin or weak to tolerate sutures. The best adheive available seems to be isobutyl cyanoacrylate.     

23-Gauge Transconjunctival Sutureless Vitrectomy: Visual Outcomes and Complications

Purpose: To report results and complications of 23-gauge transconjunctival sutureless pars plana vitrectomy for a variety of vitreoretinal diseases.

Methods: A prospective consecutive case series study was performed in 66 eyes of 66 patients. Indications for surgery were epiretinal membrane (n?=?20), rhegmatogenous retinal detachment (n?=?19: 14 pseudophakic, 5 phakic), macular hole (n?=?16), vitreous hemorrhage (n?=?5), cyclodialysis (n?=?1), intraocular lens luxation (n?=?1), asteroid hyalosis (n?=?1), congenital retinoschisis (n?=?1), and endophtalmitis (n?=?2). Main outcome measures included visual acuity, intraocular pressure, and intra- and post-operative complications.

Results: Mean patient age at time of operation was 68?±?12 years. Overall, visual acuity improved from 1.03?±?1.00 logMAR preoperatively to 0.32?±?0.33 logMAR postoperatively (p?<?0.01) after a mean follow-up time of 9.3?±?4.7 months. Mean preoperative intraocular pressure was 13.9?±?3.5 mmHg, and mean postoperative intraocular pressure was 17.9?±?9.6 mmHg on day 1 (p?<?0.01) and 14.7?±?2.8 mmHg (p?=?0.05) at final visit. Concerning complications, 2 cases of hypotony and 7 of hypertony occurred on day 1, a macular hole reopened some weeks later, and a retinal detachment recurred in one case.

Conclusion: 23-gauge transconjunctival sutureless vitrectomy is an effective and safe technique for a variety of vitreoretinal diseases.