Advanced preoperative three-dimensional planning decreases the surgical complications of using large-for-size grafts in pediatric living donor liver transplantation

BackgroundUsing “large-for-size” liver graft, graft-to-recipient weight ratio (GRWR) ≥4%, has been debated in pediatric liver transplantation due to possible graft compartment after abdomen closure. Meticulous preoperative evaluation with three-dimensional (3D) techniques may prevent these problems. This study compared the safety of large-for-size grafts in pediatric living donor liver transplantation (PLDLT) during the eras with or without 3D planning.MethodsWe defined the 3D era was after November 2017 due to our first implication of 3D printing for surgical planning and subsequently developing a 3D simulation implanting model. From November 2004 to July 2021, we enrolled 30 PLDLT patients with body weight (BW) < 10 kg and categorized them into conventional group: GRWR ≥4% before the 3D era (n = 9), 3D group: GRWR ≥4% in the 3D era (n = 8), and control group: GRWR <4% (n = 13). We followed and compared their clinical outcomes.ResultsThe 3D group had the lowest BW and the highest graft volume reduction rate, with all receiving modified left lateral segments (LLS), such as reduced LLS (n = 2), hyperreduced LLS (n = 5), and segment 2 monosegment (n = 1). Overall postoperative complications were similar in conventional and control groups but significantly lower in the 3D group (OR 0.06, 95% CI 0.006?0.70, p = 0.025). However, all groups had similar graft and patient survival at 1, 2, and 4 years.ConclusionAdvanced preoperative 3D planning can decrease post-transplant complications and increase the safety of large-for-size grafts in PLDLT.Level of EvidenceType of study: Retrospective comparative study; Evidence level: Level III     

Relative motion flexion following zone I-III flexor tendon repair: Concepts,evidence and practice.

Study DesignNarrative review and case series.IntroductionThe relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis.MethodsWe reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data.ResultsWe report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients.DiscussionWe discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use.ConclusionsThere is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.     

Complications of percutaneous image-guided screw fixation: An analysis of 94 consecutive patients

PurposeThe purpose of this study was to retrospectively assess the safety profile of percutaneous image-guided screw fixation (PIGSF) for insufficiency, impending or pathological fractures.Materials and methodsFrom July 2012 to April 2020, all consecutive patients who underwent PIGSF were retrospectively included in the study. Patient characteristics, fracture type, procedural data and complications were analyzed. Complications were divided into per-procedural, early (< 24 hours) and delayed (> 24 hours) and classified into minor (grade 1-2) and major complications (grade 3-5) according to Common Terminology Criteria for Adverse Events (CTCAE) v5.0.ResultsA total of 110 fractures (40 insufficiency [36%], 53 pathological [48.5%] and 17 impending [15.5%] fractures) in 94 patients (48 women, 46 men; mean age, 62.7 ± 12.7 [SD] years; age range: 32–88 years) were treated with PIGSF during 95 procedures. Twenty-four-hours follow-up was available for all patients, and > 24-hours follow-up was available for 79 (79/110; 71.8%) fractures in 69 (69/94; 73.4%) patients. Per-procedural complications occurred in 3/110 fractures (2.7%, all minor). Early complications were reported in 4/110 fractures (3.6%, 1 major and 3 minor) and delayed ones in 14/79 fractures (17.7%, 5 major and 9 minor). The most frequent major delayed complication was infection (3/79; 3.8%).ConclusionThe rate of per-procedural and early (within 24 hours) complications following PIGSF is extremely low with most complications being minor, with major complications being delayed ones (> 24 hours).     

Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis

BackgroundDeep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes.MethodsA systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated.ResultsTwenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis.ConclusionsCompared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.     

Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery

ObjectivesMinisternotomy and right anterior minithoracotomy are the 2 main techniques applied for minimally invasive aortic valve replacement. The goal of this study is to compare early and long-term outcomes of both techniques.MethodsThe data of 2419 patients undergoing isolated minimally invasive aortic valve replacement between 1999 and 2019 were prospectively collected. Retrospectively, patients were divided into the ministernotomy group (n = 1352) and the minithoracotomy group (n = 1067).ResultsAfter propensity score matching, 986 patients remained in each group. Operation time and rate of conversion to full sternotomy were significantly higher in the minithoracotomy group than in the ministernotomy group (184.6 ± 45.2 vs 241.3 ± 68.6, relative risk, 2.54, P = .005 and .09 vs .23, relative risk, 1.45, P = .013, respectively). The 30-day mortality, excluding cardiac death, was lower in the ministernotomy group than in the minithoracotomy group (0.012 vs 0.028, relative risk, 1.41, P = .011, respectively); the intensive care unit length of stay (12.4 vs 16.5, relative risk, 1.62, P = .037, respectively) and hospital length of stay (5.4 vs 8.7, relative risk, 1.74 P = .028, respectively) were significantly longer in the minithoracotomy group. The minithoracotomy surgical approach was the strongest independent predictor of early mortality (odds ratio, 4.24 [1.67-7.35], P = .002). The actuarial survival by Kaplan–Meier analysis at 1, 3, 5, 10, and 20 years was significantly better in the ministernotomy group than in the minithoracotomy group (P = .0001). Actuarial freedom from reoperation at 5 years was 97.3% ± 4.4% in the ministernotomy group versus 95.8% ± 5.2% in the minithoracotomy group (P = .087).ConclusionsMinimally invasive aortic valve replacement using ministernotomy is associated with reduced operative time, intensive care unit stay, hospital length of stay, and postoperative morbidities and incisional pain, and improves early and long-term mortality.     

Characterizing response to a dynamic stability modeled approach for thumb carpometacarpal joint pain: A retrospective study

Study DesignRetrospective case series.IntroductionLiterature trends indicate that thumb dynamic stabilization may benefit clients with thumb carpometacarpal (CMC) joint pain and arthritis. There is minimal research investigating whether client characteristics predict responsiveness to hand therapy for thumb dynamic stabilization.Purpose of the Study1) To investigate how adults with thumb CMC joint pain responded to a hand therapy dynamic stabilization modeled intervention. 2) To determine if various client factors influenced responsiveness and to what extent.MethodsAn electronic medical record search identified adults treated from August 2009 through December 2015 for thumb CMC joint pain. Radiographs were retrospectively staged. Outcome measures were 1) Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) total disability score and 2) Numerical Pain Rating Scale (NPRS). Paired t-tests were performed to compare pre and post treatment measures. Multivariate analyses were used to investigate predictive factors.ResultsA total of 249 charts were analyzed. Large overall significant effects were noted for disability score (QuickDASH P <.001, X = 12.1, Cohen's d = 0.9). The average improvement of 2.1 (SD = 2.6) points exceeded the minimal clinically important difference (MCID) of 1.7 points on the NPRS pain scale. Significant predictors of QuickDASH Scores were radiographic staging, bilateral hand involvement and initial pain ratings. Significant predictors for change in pain scores (meeting or exceeding the minimal clinically important difference for the NPRS) were bilateral thumb involvement and initial “pain at worst” rating.ConclusionAfter completing hand therapy with a dynamic stabilization approach, clients had less pain and disability. Those who had unilateral thumb pain, or those who started with higher pain levels were most likely to have clinically meaningful improvements in pain. Clients in early CMC osteoarthritis (OA) stages responded better than those in later stages, indicating that early referral to therapy is important.     

Discriminating between benign and malignant salivary gland tumors using diffusion-weighted imaging and intravoxel incoherent motion at 3 Tesla

PurposeThe purpose of this study was to retrospectively evaluate the diagnostic performances of diffusion-weighted imaging (DWI) and intravoxel incoherent motion (IVIM) for discriminating between benign and malignant salivary gland tumors (SGTs).Materials and methodsSixty-seven patients with 71 SGTs who underwent MRI examination at 3 Tesla were included. There were 34 men and 37 women with a mean age of 57 ± 17 (SD) years (age range: 20–90 years). SGTs included 21 malignant tumors (MTs) and 50 benign SGTs (33 pleomorphic adenomas [PAs] and 17 Warthin's tumors [WTs]). For each SGT, DWI and IVIM parameters, mean, skewness, and kurtosis of apparent diffusion coefficient (ADC), pure diffusion coefficient (D), pseudo-diffusion coefficient (D*) and perfusion volume fraction (f) were calculated and further compared between SGTs using univariable analysis. Areas under the curves (AUC) of receiver operating characteristic of significant parameters were compared using the Delong test.ResultsSignificant differences in ADC_mean, D_mean and D*_mean were found between SGTs (P < 0.001). The highest AUC values were obtained for ADC_mean (0.949) for identifying PAs and D*_mean (0.985) for identifying WTs and skewness and kurtosis did not outperform mean. To discriminate benign from malignant SGTs with thresholds set to maximize Youden index, IVIM and DWI produced accuracies of 85.9% (61/71; 95% CI: 75.6–93.0) and 77.5% (55/71; 95% CI: 66.0–86.5) but misdiagnosed MTs as benign in 28.6% (6/21) and 61.9% (13/21) of SGTs, respectively. After maximizing specificity to 100% for benign SGTs, the accuracies of IVIM and DWI decreased to 76.1% (54/71; 95% CI: 64.5–85.4) and 64.8% (46/71; 95% CI: 52.5–75.8) but no MTs were misdiagnosed as benign. IVIM and DWI correctly diagnosed 66.0% (33/50) and 50.0% (25/50) of benign SGTs and 46.5% (33/71) and 35.2% (25/71) of all SGTs, respectively.ConclusionIVIM is more accurate than DWI for discriminating between benign and malignant SGTs because of its advantage in detecting WTs. Thresholds set by maximizing specificity for benign SGTs may be advantageous in a clinical setting.     

An encounter with the first female Emirati plastic surgeon: Role models can be found in places where we are not always searching for them

PurposeTo demonstrate use of patient specific implants (PSIs) in the reconstruction of significant facial skeletal defects. Polyamide 12 implants were used to achieve good symmetric results with great projection and contours and minimal morbidity, all of which would not be predictably achievable with other reconstructive options.MethodsUsing a retrospective study design, three patients who had significant facial skeletal defects affecting the zygomaticomaxillary complex, frontal bone and also having an orbital component were used as subjects. The cases reported in this article were managed during the period from June 2015 to May 2016 with a minimum of 5 years follow up for all three cases. Outcomes were evaluated radiographically by overlapping postoperative x-rays with the virtual plan and also clinically using a virtual analogue scale (VAS).ResultsFor the three patients, VAS assessment for patient satisfaction yielded promising results with the first case reporting an 8, with 10 being most satisfied. For the second patient, the VAS was 7.5 and for the third patient it was 8.5. Radiographically, the difference in transverse projection on all four points did not exceed 2.48 mm. When assessing antero-posterior projection accuracy, there was an average deviation of 0.68 mm at the infraorbital rim and 0.86 mm at the zygomaticofrontal point.ConclusionThis article aims to point out the significant advantages of the use of polyamide 12 PSIs for the major facial skeletal reconstructions regarding symmetry, anatomical contours, minimal morbidity and decreased costs. A larger number of patients is needed in future studies.     

Use of trans-anastomotic tubes in congenital duodenal obstruction

AimDespite data to suggest benefit of trans- anastomotic tube (TAT) feeding in infants following repair of congenital duodenal obstruction (CDO), TAT usage is limited. We aimed to report a large series of infants with CDO treated with or without TAT in order to improve the evidence underlying this simple intervention.MethodSingle centre retrospective review of all infants CDO over a 20-year period (January 1999 – November 2020, inclusive). Important outcomes were compared between infants treated with or without TAT. Data are median [IQR].ResultsNinety-six infants were included. A TAT was placed in 54 infants (56%). Median time to full enteral feed was significantly shorter in the TAT group (6 [5–8] days vs 10 [7.5–12], p <0.001). Time to first feed was shorter in the TAT group (2 [2–2.8] days vs 3 [2–5], p<0.001). Significantly fewer infants with a TAT placed received a central venous catheter (CVC, 15% vs 76%, p <0.001). Infants without a TAT received parenteral nutrition (PN) for longer (0 [0–0] vs 7 [0–11] days, p <0.001). There was no change in length of stay between TAT and no TAT group (16 [13–21.8] vs 15 [12–21.8] days, p = 0.722). Eight infants (15%) in the TAT group required a CVC and PN. One infant in the TAT group developed a perforation that required surgical management and nine infants in the non-TAT group had complications related to the CVC (21%), including one infant that required general anaesthetic for tunnelled central line placement (2.3%).ConclusionIn infants with CDO, TAT use was associated with earlier establishment of full enteral feeds, reduced need for CVC and PN and reduced complications. Further research should focus on the barriers to wider use of TAT by surgeons and neonatologists in infants with CDO.Level III evidence     

Albumin-Bilirubin Score vs Model for End-Stage Liver Disease in Predicting Post-Hepatectomy Outcomes

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Difference in Survival in Early Kidney after Liver Transplantation Compared with Simultaneous Liver-Kidney Transplantation: Evaluating the Potential of the “Safety Net”

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Improvements in Extracorporeal Membrane Oxygenation for Primary Graft Failure After Heart Transplant

BackgroundSevere primary graft failure is a life-threatening complication of heart transplantation that may require venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Surgical practices and management strategies regarding VA-ECMO vary between and within centers.MethodsWe performed a single-center retrospective cohort study on adult patients who received VA-ECMO for primary graft failure between 2013 and 2020. Clinical data were obtained from chart review and national databases. Patients were stratified by transplantation before or after 2017, when our center adopted additional objective criteria for VA-ECMO, adopted partial-flow support, and changed from central cannulation to chimney graft arterial cannulation of brachiocephalic, axillary, or aorta. The primary outcome was survival to device weaning. Secondary outcomes were survival to discharge, survival to 1 year, complications on support, and time to sedation weaning and extubation.ResultsFrom 276 heart transplant recipients, 39 severe primary graft failure patients requiring VA-ECMO were identified. Incidence of graft failure was 13% (n = 18 of 135) pre-2017 and 15% (n = 21 of 141) post-2017. Survival at all time points improved significantly after 2017, with greatest difference in survival to device weaning (61% pre-2017 vs 100% post-2017). After controlling for other factors in multivariable Cox regression modeling, transplantation after 2017 was a predictor of reduced mortality (hazard ratio, 0.209; 95% CI, 0.06-0.71; P = .01). Significant differences were not observed in other secondary outcomes of recovery.ConclusionsThe new VA-ECMO strategy displayed reasonable survival and a remarkable improvement from the prior system.