Surgical and functional outcomes of repeat robot-assisted laparoscopic partial nephrectomy compared with repeat open partial nephrectomy

OBJECTIVES

To examine the surgical and functional outcomes of patients who have undergone repeat open partial nephrectomy (reOPN) or robot-assisted laparoscopic partial nephrectomy (reRAPN).

METHODS

Until May 2022, 3310 patients with renal tumors underwent nephron-sparing surgery (NSS) at affiliated institutions. Of these, 22 and 17 patients who underwent reOPN and reRAPN, respectively, were included in this study.

RESULTS

No significant differences were found between the groups in terms of sex, age, comorbidities, recurrent tumor size at repeat NSS, interval from recurrence to initial NSS, and nephrometry score. ReRAPN had a shorter operative time (median: 138.0 vs. 214.0 min; p = 0.0023) and less estimated blood loss (median: 50.0 vs. 255.0 mL; p = 0.0261) than reOPN. The incidence of complications with Clavien-Dindo grade ≥ 2 was higher in the reOPN group than in the reRAPN group (31.8 vs. 5.9%; p = 0.0467). The mean decrease in the estimated glomerular filtration rate at 3 months postoperatively was not significantly different between the groups. The trifecta achievement rates in the reRAPN (64.7%) and reOPN (27.3%) groups were significantly different (p = 0.0194). On multivariate analysis, age and surgical method were significant predictors of trifecta achievement after partial nephrectomy.

CONCLUSIONS

There were no differences in postoperative renal functional outcomes between reOPN and reRAPN. ReRAPN is superior to reOPN in terms of surgical burden. Therefore, ReRAPN is an important minimally invasive surgery for recurrent renal cell carcinoma.

Clinical Outcomes and Risk Factors for Re-Revision Due to Trunnion Corrosion in Primary Metal-on-Polyethylene Total Hip Arthroplasty

BACKGROUND

There is a paucity of literature regarding the mid-term (greater than 2 years) outcomes of revision for adverse local tissue reaction (ALTR) to metal debris due to corrosion at the head-neck junction (trunnionosis) in metal-on-polyethylene (MoP) total hip arthroplasty (THA), and risk factors for re-revision remain largely unknown. We aimed to report the re-revision-free survival and functional outcomes for this patient population and to identify risk factors for re-revision.

METHODS

A total of 80 hips (79 patients) with a MoP THA who had undergone revision for trunnionosis at our institution were included. The mean study follow-up from index trunnionosis revision was 4.6 years (range, 2.0 to 9.4). Kaplan-Meier survival analysis was performed with all-cause re-revision as the endpoint, and multivariate logistic regression was used to identify risk factors for re-revision.

RESULTS

We saw that twenty-one hips (26%) underwent re-revision at a mean of 8.0 months (range, 0.03 to 36.3) after the index trunnionosis revision, most commonly for instability and infection. The two- and five-year all-cause re-revision-free survival rates were 75.0 and 73.2%, respectively. The mean Oxford Hip Score was 33.7 (range, 11 to 48); 76% were satisfied, and 24% were dissatisfied with their hip. Multivariate analysis identified not undergoing a cup revision (Odds Ratio (OR) 4.5, 95% Confidence Interval (CI) 1.03 to 19.7) and time from primary THA to the index trunnionosis revision (OR 0.77, 95% CI 0.62 to 0.97) as risk factors for undergoing re-revision.

CONCLUSION

The risk of early re-revision for these patients is high (26%), mostly due to infection and instability, and functional outcomes are fair. Not performing a cup revision appears to be a risk factor for re-revision, as is the shorter time from primary THA to trunnionosis revision.

Repeat Surgery for Vestibular Schwannomas: An Institutional Case Series

Introduction  Vestibular schwannomas (VSs) are treated with microsurgery and/or radiosurgery. Repeat resection is rare, and few studies have reported postoperative outcomes. The objective of this study was to describe clinical characteristics and outcomes in patients undergoing repeat surgery for VS. Methods  All adult (≥ 18 years) patients undergoing VS resection between 2003 and 2022 at our institution were retrospectively reviewed to identify patients who underwent repeat surgery of an ipsilateral VS following prior gross-total (GTR) or subtotal resection. Patient, radiographic, and clinical characteristics were reviewed. Primary outcomes were postoperative tumor volume, extent of resection, postoperative cranial nerve deficits, and time to further tumor progression. Results  Of 102 patients undergoing VS resection, 6 (5.9%) had undergone repeat surgery. Median (range) follow-up was 20 (5-117) months. Three patients were female. Median age was 56 (36-60) years. Median pre- and postoperative tumor volumes were 8.2 (1.8-28.2) cm 3 and 0.4 (0-3.8) cm 3 . GTR was achieved in two patients. Four patients had higher House-Brackmann scores at last follow-up, but none had tumor progression. Conclusion  In this small cohort of patients, repeat resection of recurrent or progressive VS can effectively reduce tumor volume with acceptable perioperative outcomes.

Clinical outcomes of pediatric hemispherectomy following unsuccessful subhemispheric resection for refractory epilepsy: a case review study

OBJECTIVE

Epilepsy surgery remains one of the most underutilized procedures in epilepsy despite its proven superiority to other available therapies. This underutilization is greater in patients in whom initial surgery fails. This case series examined the clinical characteristics, reasons for initial surgery failure, and outcomes in a cohort of patients who underwent hemispherectomy following unsuccessful smaller resections for intractable epilepsy (subhemispheric group [SHG]) and compared them to those of a cohort of patients who underwent hemispherectomy as the first surgery (hemispheric group [HG]). The objective of this paper was to determine the clinical characteristics of patients in whom a small, subhemispheric resection failed, who went on to become seizure free after undergoing a hemispherectomy.

METHODS

Patients who underwent hemispherectomy at Seattle Children's Hospital between 1996 and 2020 were identified. Inclusion criteria for SHG were as follows: 1) patients ≤ 18 years of age at the time of hemispheric surgery; 2) initial subhemispheric epilepsy surgery that did not produce seizure freedom; 3) hemispherectomy or hemispherotomy after the subhemispheric surgery; and 4) follow-up for at least 12 months after hemispheric surgery. Data collected included the following: patient demographics; seizure etiology; comorbidities; prior neurosurgeries; neurophysiological studies; imaging studies; and surgical details-plus surgical, seizure, and functional outcomes. Seizure etiology was classified as follows: 1) developmental, 2) acquired, or 3) progressive. The authors compared SHG to HG in terms of demographics, seizure etiology, and seizure and neuropsychological outcomes.

RESULTS

There were 14 patients in the SHG and 51 patients in the HG. All patients in the SHG had Engel class IV scores after their initial resective surgery. Overall, 86% (n = 12) of the patients in the SHG had good posthemispherectomy seizure outcomes (Engel class I or II). All patients in the SHG who had progressive etiology (n = 3) had favorable seizure outcomes, with eventual hemispherectomy (1 each with Engel classes I, II, and III). Engel classifications posthemispherectomy between the groups were similar. There were no statistical differences in postsurgical Vineland Adaptive Behavior Scales Adaptive Behavior Composite scores or postsurgical full-scale IQ scores between groups when accounting for presurgical scores.

CONCLUSIONS

Hemispherectomy as a repeat surgery after unsuccessful subhemispheric epilepsy surgery has a favorable seizure outcome, with stable or improved intelligence and adaptive functioning. Findings in these patients are similar to those in patients who had hemispherectomy as their first surgery. This can be explained by the relatively small number of patients in the SHG and the higher likelihood of hemispheric surgeries to resect or disconnect the entire epileptogenic lesion compared to smaller resections.

An expanded role for surgery in grade 3 1p/19q co-deleted oligodendroglioma

Background

Grade 3 1p/19q co-deleted oligodendroglioma is an uncommon primary CNS tumor with a high rate of progression and recurrence. This study examines the benefit of surgery after progression and identifies predictors of survival.

Methods

This is a single-institution retrospective cohort study of consecutive adult patients with anaplastic or grade 3 1p/19q co-deleted oligodendroglioma diagnosed between 2001 and 2020.

Results

Eighty patients with 1p/19q co-deleted grade 3 oligodendroglioma were included. The median age was 47 years (interquartile range 38-56) and 38.8% were women. All patients underwent surgery, including gross total resection (GTR) for 26.3% of patients, subtotal resection (STR) for 70.0% of patients, and biopsy for 3.8% of patients. Forty-three cases (53.8%) progressed at a median of 5.6 years, and the median overall survival (OS) was 14.1 years. Among 43 cases of progression or recurrence, 21 (48.8%) underwent another resection. Patients who underwent a second operation had improved OS (P = .041) and survival after progression/recurrence (P = .012), but similar time to subsequent progression as patients who did not have repeat surgery (P = .50). Predictors of mortality at initial diagnosis included a preoperative Karnofsky Performance Status (KPS) under 80 (hazard ratio [HR] 5.4; 95% CI 1.5-19.2), an STR or biopsy rather than GTR (HR 4.1; 95% CI 1.2-14.2), and a persistent postoperative neurologic deficit (HR 4.0; 95% CI 1.2-14.1).

Conclusions

Repeat surgery is associated with increased survival, but not time to subsequent progression for progressing or recurrent 1p/19q co-deleted grade 3 oligodendrogliomas recur. Mortality is associated with a preoperative KPS under 80, lack of GTR, and persistent postoperative neurologic deficits after the initial surgery.

Reoperation for Recurrent and Persistent Cushing's Disease without Visible MRI Findings

PURPOSE

Transsphenoidal surgery is the first-line treatment for Cushing's disease (CD), even with negative preoperative magnetic resonance imaging (MRI) results. Some patients with persistent or recurring hypercortisolism have negative MRI findings after the initial surgery. We aimed to analyze the efficacy of repeat surgery in two groups of patients and determine if there is an association between positive MRI findings and early remission.

PATIENTS AND METHODS

Clinical, imaging, and biochemical information of 42 patients who underwent repeat surgery by a single neurosurgeon between 2002 and 2021 was retrospectively analyzed. We compared the endocrinological, histopathological, and surgical outcomes before and after repeat surgery among 14 CD patients with negative MRI findings and 28 patients with positive MRI findings.

RESULTS

Immediate remission was achieved in 29 patients (69.0%) who underwent repeat surgery. Among all patients, 28 (66.7%) had MRI findings consistent with solid lesions. There was no significant difference in remission rates between the recurrence and persistence groups (77.8% vs. 57.1%, odds ratio = 2.625, 95% confidence interval = 0.651 to 10.586). Patients in remission after repeat surgery were not associated with positive MRI findings (odds ratio = 3.667, 95% confidence interval = 0.920 to 14.622).

CONCLUSIONS

In terms of recurrence, repeat surgery in patients with either positive or negative MRI findings showed reasonable remission rates. For persistent disease with positive MRI findings, repeat surgery is still an option; however, more solid evidence is needed to determine if negative MRI findings are predictors for failed reoperations for persistent hypercortisolism.

Rehabilitation Outcomes for Patients with Motor Deficits after Initial and Repeat Brain Tumor Surgery

Repeat surgery is often required to treat brain tumor recurrences. Here, we compared the functional state and rehabilitation of patients undergoing initial and repeat surgery for brain tumors to establish their individual risks that might impact management. In total, 835 patients underwent operations, and 139 (16.6%) required rehabilitation during the inpatient stay. The Karnofsky performance status, Barthel index, and the modified Rankin scale were used to assess functional status, and the gait index was used to assess gait efficiency. Motor skills, postoperative complications, and length of hospital stay were recorded. Patients were classified into two groups: first surgery (n = 103) and repeat surgery (n = 30). Eighteen percent of patients required reoperations, and these patients required prolonged postoperative rehabilitation as often as those operated on for the first time. Rehabilitation was more often complicated in the repeat surgery group (p = 0.047), and the complications were more severe and persistent. Reoperated patients had significantly worse motor function and independence in activities of daily living before surgery and at discharge, but the deterioration after surgery affected patients in the first surgery group to a greater extent according to all metrics (p < 0.001). The length of hospital stay was similar in both groups. These results will be useful for tailoring postoperative rehabilitation during a hospital stay on the neurosurgical ward as well as planning discharge requirements after leaving the hospital.

Evaluating the safety and efficacy of microwave ablation in treatment of cervical metastatic lymph nodes of papillary thyroid carcinoma compared to repeat surgery

OBJECTIVE

To evaluate the safety and efficacy of microwave ablation (MWA) versus repeat surgery for treating metastatic lymph nodes (MLNs) in papillary thyroid carcinoma (PTC).

METHODS

Between July 2017 and October 2020, 67 patients were enrolled in this retrospective study. 19 and 48 patients underwent MWA and repeat surgery, respectively. The primary and secondary endpoints were recurrence-free survival and complication rates, respectively. The largest diameter, volume and volume reduction ratio (VRR) were analyzed before and after MWA. The effects of different ablation powers on the largest diameter, volume and VRR were investigated. Pre and posttreatment variables (e.g., baseline characteristics, serum thyroglobulin [Tg] levels, hospitalization time, treatment costs, recurrence-free survival and complication rates) were compared between groups.

RESULTS

The largest diameter and volume postablation at each follow-up were smaller than the preablation levels (p < 0.05), except at the 1-month follow-up (p > 0.05). The largest diameter, volume, and VRR among the different ablation powers were not significantly different (p > 0.05). The mean serum Tg levels and biochemical remission rates were not significantly different between the groups (p > 0.05). Compared to reoperation, MWA had a shorter hospitalization time and lower treatment cost (p < 0.001). Total and minor complications were higher in the reoperation group (p < 0.05), but major complications were comparable (p > 0.05). The recurrence-free survival rate between groups was not significantly different (p = 0.401). The 1- and 3-year recurrence-free survival rates were comparable between the groups.

CONCLUSIONS

MWA may be a safe and effective alternative to repeat surgery for treating MLNs of PTC in select patients.

Multicenter Propensity Score-Based Study of Laparoscopic Repeat Liver Resection for Hepatocellular Carcinoma: A Subgroup Analysis of Cases with Tumors Far from Major Vessels

Simple Summary

Less morbidity is considered among the advantages of laparoscopic liver resection for HCC patients. However, our previous international, multi-institutional study of laparoscopic repeat liver resection (LRLR) failed to prove it. We hypothesize that these results may be since the study included complex cases performed during the procedure’s developing stage. To examine it, subgroup analysis based on propensity score were performed, defining the proximity of the tumors to major vessels as the complexity. A propensity score matching earned 115 each patient of LRLR and open repeat liver resection (ORLR) without the proximity to major vessels, and the outcomes were compared. With comparable operation time and long-term outcome, less blood loss and less morbidity were shown in LRLR group than ORLR. Even in its worldwide developing stage, LRLR for HCC patients could be beneficial in blood loss and morbidity for the patients with less complexity in surgery.

Abstract

Less morbidity is considered among the advantages of laparoscopic liver resection (LLR) for HCC patients. However, our previous international, multi-institutional, propensity score-based study of emerging laparoscopic repeat liver resection (LRLR) failed to prove this advantage. We hypothesize that these results may be since the study included complex LRLR cases performed during the procedure’s developing stage. To examine it, subgroup analysis based on propensity score were performed, defining the proximity of the tumors to major vessels as the indicator of complex cases. Among 1582 LRLR cases from 42 international high-volume liver surgery centers, 620 cases without the proximity to major vessels (more than 1 cm far from both first–second branches of Glissonian pedicles and major hepatic veins) were selected for this subgroup analysis. A propensity score matching (PSM) analysis was performed based on their patient characteristics, preoperative liver function, tumor characteristics and surgical procedures. One hundred and fifteen of each patient groups of LRLR and open repeat liver resection (ORLR) were earned, and the outcomes were compared. Backgrounds were well-balanced between LRLR and ORLR groups after matching. With comparable operation time and long-term outcome, less blood loss (283.3±823.0 vs. 603.5±664.9 mL, p = 0.001) and less morbidity (8.7 vs. 18.3 %, p = 0.034) were shown in LRLR group than ORLR. Even in its worldwide developing stage, LRLR for HCC patients could be beneficial in blood loss and morbidity for the patients with less complexity in surgery.

Management of patients with persistent or recurrent Cushing's disease after initial pituitary surgery

INTRODUCTION

Treatment options for persistent and recurrent Cushing's disease (CD) include an individualized approach for repeat surgery, medical treatment, radiation therapy (RT), and bilateral adrenalectomy (BLA).

AREAS COVERED

In this expert opinion perspective, the authors review the latest treatment(s) for persistent/recurrent CD. A PubMed search was undertaken (English articles through May 2020) and relevant articles discussed. Repeat pituitary surgery should be considered in most patients with proven hypercortisolism; there is potential for cure with low risk of major complications. Medical therapy is valuable either alone, while awaiting the effects of RT, or in preparation for BLA. Medical therapy includes steroidogenesis inhibitors, agents that act at the pituitary or glucocorticoid receptor level, and novel agents in development. Radiation therapy has been used successfully to treat CD, but hypopituitarism risk and delayed efficacy (improved with radiosurgery) are major drawbacks. Laparoscopic BLA is safe and effective in patients with severe, difficult-to-manage hypercortisolism, but long-term follow-up is required as corticotroph tumor progression can develop.

EXPERT OPINION

Treatment of persistent/recurrent CD is challenging. Most patients require >1 therapy to achieve long-lasting remission. There is currently no ideal single treatment option that provides high and rapid efficacy, low adverse effects, and preserves normal pituitary-adrenal axis function.

Laparoscopic repeat liver resection

Recurrence of liver cancers inside the liver are often treated with liver resection (LR). However, increased risks of complications and conversion during operation were reported in laparoscopic repeat LR (LRLR). The indication is still controversial. One multi-institutional propensity score matching analysis of LRLR vs open repeat LR for hepatocellular carcinoma, two propensity score matching analyses for colorectal metastases, and two meta-analyses including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastases, and other tumors have been reported to date. LRLR was reported with better to comparable short-term and similar long-term outcomes. Furthermore, the shorter operation time and the smaller amount of intraoperative bleeding for LRLR was reported for the patients who had undergone laparoscopic rather than open LR as an earlier procedure. The speculations are presented, that complete dissection of adhesion can be dodged and laparoscopic minor repeated LR can minimize the liver functional deterioration in cirrhotic patients. LRLR, as a powerful local therapy, could contribute to the long-term outcomes of those with deteriorated liver function. However, the procedure is now in its developing stage worldwide and further accumulation of experiences and evaluation are needed.

Mesh inlay, mesh kit or native tissue repair for women having repeat anterior or posterior prolapse surgery: randomised controlled trial (PROSPECT)

OBJECTIVE

To compare standard (native tissue) repair with synthetic mesh inlays or mesh kits.

DESIGN

Randomised controlled trial.

SETTING

Thirty-three UK hospitals.

POPULATION

Women having surgery for recurrent prolapse.

METHODS

Women recruited using remote randomisation.

MAIN OUTCOME MEASURES

Prolapse symptoms, condition-specific quality-of-life and serious adverse effects.

RESULTS

A Mean Pelvic Organ Prolapse Symptom Score at 1 year was similar for each comparison (standard 6.6 versus mesh inlay 6.1, mean difference [MD] -0.41, 95% CI -2.92 to 2.11: standard 6.6 versus mesh kit 5.9, MD -1.21 , 95% CI -4.13 to 1.72) but the confidence intervals did not exclude a minimally important clinical difference. There was no evidence of difference in any other outcome measure at 1 or 2 years. Serious adverse events, excluding mesh exposure, were similar at 1 year (standard 7/55 [13%] versus mesh inlay 5/52 [10%], risk ratio [RR] 1.05 [0.66-1.68]: standard 3/25 [12%] versus mesh kit 3/46 [7%], RR 0.49 [0.11-2.16]). Cumulative mesh exposure rates over 2 years were 7/52 (13%) in the mesh inlay arm, of whom four women required surgical revision; and 4/46 in the mesh kit arm (9%), of whom two required surgical revision.

CONCLUSIONS

We did not find evidence of a difference in terms of prolapse symptoms from the use of mesh inlays or mesh kits in women undergoing repeat prolapse surgery. Although the sample size was too small to be conclusive, the results provide a substantive contribution to future meta-analysis.

TWEETABLE ABSTRACT

There is not enough evidence to support use of synthetic mesh inlay or mesh kits for repeat prolapse surgery.

Long-term outcomes of reoperations in epilepsy surgery

OBJECTIVE

To analyze longitudinal seizure outcomes following epilepsy surgery, including reoperations, in patients with intractable focal epilepsy.

METHODS

Clinicoradiological characteristics of patients who underwent epilepsy surgery from 1995 to 2016 with follow-up of ≥1 year were reviewed. In patients undergoing reoperations, the latest resection was considered the index surgery. The primary outcome was complete seizure freedom (Engel I) at last follow-up. Potentially significant outcome variables were first identified using univariate analyses and then fit in multivariate Cox proportional hazards models.

RESULTS

Of 898 patients fulfilling study criteria, 110 had reoperations; 92 had one resection prior to the index surgery and 18 patients had two or more prior resective surgeries. Two years after the index surgery, 69% of patients with no prior surgeries had an Engel score of I, as opposed to only 42% of those with one prior surgery, and 33% of those with two or more prior resections (P < .001). Among surgical outcome predictors, the number of prior epilepsy surgeries, female sex, lesional initial magnetic resonance imaging, no prior history of generalization, and pathology correlated with better seizure outcomes on univariate analysis. However, only sex (P = .011), history of generalization (P = .016), and number of prior surgeries (P = .002) remained statistically significant in the multivariate model.

SIGNIFICANCE

Although long-term seizure control is possible in patients with failed prior epilepsy surgery, the chances of success diminish with every subsequent resection. Outcome is additionally determined by inherent biological markers (sex and secondary generalization tendency), rather than traditional outcome predictors, supporting a hypothesis of "surgical refractoriness."

Repeat Surgery in Chronic Aortic Dissection: A New Technique without Touching the Native Aorta

BACKGROUND

 Repeat surgery of the chronically dissected aorta following repair of a Type-A acute aortic dissection (AAD) still represents a challenge. The proposed surgical options are as follows: (1) staged procedure with elephant trunk (ET) technique, (2) traditional frozen elephant trunk (FET) intervention, and (3) beating heart cerebral vessel debranching followed by thoracic endovascular aortic repair (TEVAR). However, a marked enlargement of the proximal descending thoracic aorta might make it difficult to perform FET/ET intervention. Furthermore, because in conventional surgery for AAD, a prosthetic graft replacement is generally limited to the ascending aorta, and in repeat surgery, this short Dacron graft rarely provides enough room to allow a beating heart cerebral vessel debranching and obtaining a reliable landing zone for the implantation of a firmly anchored stent graft.

METHODS

 We retrospectively reviewed all the five consecutive patients treated in our institution, between 2014 and 2017, for chronic aortic dissection after successful surgical treatment of acute Type-A aortic dissection with graft replacement limited to the ascending aorta. The five patients underwent repair utilizing a modified FET technique with total aortic arch and upper descending aorta exclusion without touching the native dissected aorta.

RESULTS

 No early- or midterm mortality was observed. Mean time interval between the initial and the reoperative procedure was 26 months (range, 3-80 months). No patient had a minor/major neurologic event. Mean circulatory arrest time was 16 minutes (range, 11-25 minutes). Mean follow-up time was 22 months (range, 9-42 months).

CONCLUSIONS

 We report our initial experience with a modified FET technique realized by anastomosing the stent graft with the previously implanted ascending aortic graft in Hishimaru's zone 0 and by rerouting all cerebral vessels without "touching" the native chronically dissected aorta. A larger number of patients and a longer follow-up will be required to confirm these initial encouraging results.

Enhancing outcomes of endoscopic vertical approach hemispherotomy: understanding the role of "temporal stem" residual connections causing recurrence of seizures

OBJECTIVE

The authors sought to analyze the residual connections formed by the temporal stem as a cause for seizure recurrence following endoscopic vertical interhemispheric hemispherotomy and to review and compare lateral approach (perisylvian) with vertical approach surgical techniques to highlight the anatomical factors responsible for residual connections.

METHODS

This study was a retrospective analysis of patients who underwent endoscopic hemispherotomy for drug-resistant epilepsy. Postoperative MR images were analyzed. Specific attention was given to anatomical 3D-acquired thin-section T1 images to assess the extent of disconnection, which was confirmed with a diffusion tensor imaging sequence. Cadaver brain dissection was done to analyze the anatomical factors responsible for persistent connections.

RESULTS

Of 39 patients who underwent surgery, 80% (31/39) were seizure free (follow-up of 23.61 ± 8.25 months) following the first surgery. Thirty patients underwent postoperative MRI studies, which revealed persistent connections in 14 patients (11 temporal stem only; 3 temporal stem + amygdala + splenium). Eight of these 14 patients had persistent seizures. In 4 of these 8 patients, investigations revealed good concordance with the affected hemisphere, and repeat endoscopic disconnection of the residual connection was performed. Two of the 8 patients were lost to follow-up, and 2 had bihemispheric seizure onset. The 4 patients who underwent repeat endoscopic disconnection had seizure-free outcomes following the second surgery, increasing the good outcome total among all patients to 90% (35/39). Cadaveric brain dissection analysis revealed the anatomical factors responsible for the persistence of residual connections.

CONCLUSIONS

In endoscopic vertical approach interhemispheric hemispherotomy (and also vertical approach parasagittal hemispherotomy) the temporal stem, which lies deep and parallel to the plane of disconnection, is prone to be missed, which might lead to persistent or recurrent seizures. The recognition of this limitation can lead to improved seizure outcome. The amygdala and splenium are areas less commonly prone to be missed during surgery.

The relationship between repeat resection and overall survival in patients with glioblastoma: a time-dependent analysis

OBJECTIVEPrevious studies assessed the relationship between repeat resection and overall survival (OS) in patients with glioblastoma, but ignoring the timing of repeat resection may have led to biased conclusions. Statistical methods that take time into account are well established and applied consistently in other medical fields. The goal of this study was to illustrate the change in the effect of repeat resection on OS in patients with glioblastoma once timing of resection is incorporated.METHODSThe authors conducted a retrospective study of patients initially diagnosed with glioblastoma between January 2005 and December 2014 who were treated at Memorial Sloan Kettering Cancer Center. Patients underwent at least 1 craniotomy with both pre- and postoperative MRI data available. The effect of repeat resection on OS was assessed with time-dependent extended Cox regression controlling for extent of resection, initial Karnofsky Performance Scale score, sex, age, multifocal status, eloquent status, and postoperative treatment.RESULTSEighty-nine (55%) of 163 patients underwent repeat resection with a median time between resections of 7.7 months (range 0.5-50.8 months). Median OS was 18.8 months (95% confidence interval [CI] 16.3-20.5 months) from initial resection. When timing of repeat resection was ignored, repeat resection was associated with a lower risk of death (hazard ratio [HR] 0.62, 95% CI 0.43-0.90, p = 0.01); however, when timing was taken into account, repeat resection was associated with a higher risk of death (HR 2.19, 95% CI 1.47-3.28, p < 0.001).CONCLUSIONSIn this study, accounting for timing of repeat resection reversed its protective effect on OS, suggesting repeat resection may not benefit OS in all patients. These findings establish a foundation for future work by accounting for timing of repeat resection using time-dependent methods in the evaluation of repeat resection on OS. Additional recommendations include improved data capture that includes mutational data, development of algorithms for determining eligibility for repeat resection, more rigorous statistical analyses, and the assessment of additional benefits of repeat resection, such as reduction of symptom burden and enhanced quality of life.

Cardiac surgery in the heart transplant recipient: Outcome analysis and long-term results

BACKGROUND

Survival rates following cardiac transplantation continue to improve. Due to the scarcity of available organs, extended donor criteria have become more prevalent in clinical practice. In this context, the risk of developing cardiac pathology requiring surgical correction is increasing.

METHODS

Between January 1991 and October 2010, a total of 479 patients received cardiac transplantations at the University Hospital Heidelberg. Of those, 18 (3.8%) patients required subsequent cardiac surgery until 2018. Short- and long-term analyses were performed.

RESULTS

Indications for cardiac surgery included valvular disease (n = 16) with the majority of cases affecting the tricuspid valve (n = 10), while 6 patients received mitral valve surgery, of whom 3 patients underwent concomitant valve surgery. Other indications included CABG (n = 1) and re-transplantation (n = 1) for allograft dysfunction. Mean follow-up time was 6.5 years, while mean interval to surgery was 6.0 years. Early mortality was 11.1% (n = 2), while overall survival at 1, 5, and 10 years were, 88.1%, 81.4%, and 52.2%, respectively. Compared to an overall survival of that transplant cohort at 1, 5, and 10 years of 76.7%, 66.7%, and 52.4% percent, respectively (P = .271).

CONCLUSION

According to our data, redo cardiac surgery can be performed with acceptable mortality and morbidity. Atrioventricular valve pathology plays a chief role in these patients.

Reoperation after failed resective epilepsy surgery in children

OBJECTIVE Although epilepsy surgery is an effective treatment option, at least 20%-40% of patients can continue to experience uncontrolled seizures resulting from incomplete resection of the lesion, epileptogenic zone, or secondary epileptogenesis. Reoperation could eliminate or improve seizures. Authors of this study evaluated outcomes following reoperation in a pediatric population. METHODS A retrospective single-center analysis of all patients who had undergone resective epilepsy surgery in the period from 2001 to 2013 was performed. After excluding children who had repeat hemispherotomy, there were 24 children who had undergone a second surgery and 2 children who had undergone a third surgery. All patients underwent MRI and video electroencephalography (VEEG) and 21 underwent magnetoencephalography (MEG) prior to reoperation. RESULTS The mean age at the first and second surgery was 7.66 (SD 4.11) and 10.67 (SD 4.02) years, respectively. The time between operations ranged from 0.03 to 9 years. At reoperation, 8 patients underwent extended cortical resection; 8, lobectomy; 5, lesionectomy; and 3, functional hemispherotomy. One year after reoperation, 58% of the children were completely seizure free (International League Against Epilepsy [ILAE] Class 1) and 75% had a reduction in seizures (ILAE Classes 1-4). Patients with MEG clustered dipoles were more likely to be seizure free than to have persistent seizures (71% vs 40%, p = 0.08). CONCLUSIONS Reoperation in children with recurrent seizures after the first epilepsy surgery could result in favorable seizure outcomes. Those with residual lesion after the first surgery should undergo complete resection of the lesion to improve seizure outcome. In addition to MRI and VEEG, MEG should be considered as part of the reevaluation prior to reoperation.

Reoperation for urinary incontinence: a nationwide cohort study, 1998-2007

BACKGROUND

The synthetic midurethral slings were introduced in the 1990s and were rapidly replaced the Burch colposuspension as the gold standard treatment for urinary incontinence. It has been reported that the retropubic midurethral tape has an objective and subjective cure rate of 85% at 5 years of follow-up, but the rate of reoperation after retropubic midurethral tape at the long-term follow-up is less well described. The existing literature specifies an overall lifetime rate of reoperation of about 8-9% after an initial operation for urinary incontinence. There are, however, conflicting statements about the risk of reoperation after specific surgical procedures for urinary incontinence.

OBJECTIVE

The objective of the study was to describe the cumulative incidence of reoperation within a 5 year period after different types of surgical procedures for urinary incontinence based on a nationwide population.

STUDY DESIGN

We used the Danish National Patient Registry to identify women who had surgery for urinary incontinence from 1998 through 2007 and the outcome was a reoperation within 5 years. Kaplan-Meier curves were used to estimate the rate of reoperation for 6 types of surgery for urinary incontinence (retropubic midurethral tape, transobturator tape, urethral injection therapy, Burch colposuspension, pubovaginal slings, and miscellaneous operations). Cox proportional hazard models were used to estimate the hazard ratio (HR) with 95% confidence intervals (CIs), adjusted for factors suspected to be associated with reoperation.

RESULTS

A total of 8671 women (mean age, 56.1 years, range 6.7-93.7 years) underwent surgical treatment for urinary incontinence. Among these women, 5820 (67%) received a synthetic midurethral sling at baseline. The cumulative incidence of reoperation after any surgical treatment for urinary incontinence was 10%. The lowest rate of reoperation was observed among women having pubovaginal slings (6%), retropubic midurethral tape (6%) and Burch colposuspension (6%) followed by transobturator tape (9%), and miscellaneous operations (12%), whereas the highest observed risk was for urethral injection therapy (44%). In a Cox proportional hazard model that adjusted for age, department volume, and calendar effect, the transobturator tape carried a 2-fold higher risk of reoperation (HR, 2.1; 95% CI, 1.5-2.9), and urethral injection therapy carried a 12 fold-higher risk (HR, 11.5; 95% CI, 9.3-14.3) compared with retropubic midurethral tape.

CONCLUSION

This nationwide cohort study provides physicians with a representative evaluation of the rate of reoperations after surgical procedures for urinary incontinence. Pubovaginal slings, Burch colposuspension, and retropubic midurethral tape had a similar risk of reoperation (6%). Women who were operated with transobturator tape had a significantly higher risk of reoperation compared with retropubic midurethral tape.

Prevalence of Metatarsus Adductus in Symptomatic Hallux Valgus and Its Influence on Functional Outcome

BACKGROUND

Metatarsus adductus (MA) increases the risk of developing symptomatic hallux valgus (HV). This study aimed to determine the prevalence of MA in patients with symptomatic HV and to evaluate how it affected the functional outcome after scarf osteotomy.

METHODS

Between January 2007 and June 2012, a total of 206 patients who underwent scarf osteotomy for symptomatic HV at a tertiary hospital were included. The metatarsus adductus angle (MAA) was determined using the Modified Sgarlato method, and these patients were categorized into 2 groups: MA (MAA > 20 degrees); and Control (MAA ≤ 20 degrees). The patients were prospectively followed for 2 years.

RESULTS

The prevalence of MA was 33% (68/206) with a mean MAA of 24 ± 4 degrees (range = 20-39). There was a 21 ± 12 degrees and 18 ± 9 degrees improvement in hallux valgus angle for the MA and Control groups, respectively (P = .061), whereas there was a 6 ± 4 degrees and 6 ± 3 degrees improvement in intermetartarsal angle for the MA and Control groups, respectively (P = .475). The visual analog scale, AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, and Physical and Mental Component Scores were comparable between the 2 groups both preoperatively and at 2 years' follow-up (all P > .05). Two patients in the control group required revision surgery for recurrence symptomatic HV.

CONCLUSION

The authors conclude that MA did not predispose the patient to poorer functional outcome after scarf osteotomy with the advent of good operative techniques.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Effect of Obesity on Outcome of Hallux Valgus Surgery

BACKGROUND

Obesity is a global epidemic, but its effect on foot and ankle surgeries is not well defined. This study aimed to investigate the influence of obesity on functional outcome scores, incidence of postoperative surgical site infection (SSI), and repeat surgery after hallux valgus (HV) corrective surgery.

METHODS

Between January 2007 and December 2011, 452 patients who underwent HV corrective surgery at a tertiary hospital were evaluated. They were categorized into 2 groups based on their body mass index (BMI): (1) BMI less than 30 kg/m(2) (control); (2) BMI 30 kg/m(2) or more (obese). The patients were prospectively followed for 2 years.

RESULTS

Patients in the obese group were significantly older by 4 years (95% CI, 1-7 years) (P = .043). The preoperative American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) Scale and Physical Component Score were 6 points (95% CI, 1-11 points) and 3 points (95% CI, 1-6 points) poorer, respectively, in the obese group (P = .014 and P = .032, respectively). However, the Visual Analog Scale, AOFAS Hallux MTP-IP Scale, Physical Component Score, and Mental Component Score were comparable between the 2 groups at 6 months and 2 years of follow-up (all P > .05). Eleven patients (3%) in the control group and 1 patient in the obese group (2%) developed postoperative SSI (P = .777). Nine patients (2%) in the control group and 7 patients in the obese group (14%) required repeat surgery for complications (P < .001).

CONCLUSION

The authors conclude that while it is important to warn obese patients of the significantly higher risk of repeat surgery, these patients should not be excluded from undergoing HV surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Surgery for endometriosis-associated infertility: do we exaggerate the magnitude of effect?

OBJECTIVE

Surgery remains the mainstay in the diagnosis and management of endometriosis. The number of surgeries performed for endometriosis worldwide is ever increasing, however do we have evidence for improvement of infertility after the surgery and do we exaggerate the magnitude of effect of surgery when we counsel our patients? The management of patients who failed the surgery could be by repeat surgery or assisted reproduction. What evidence do we have for patients who fail assisted reproduction and what is their best chance for achieving pregnancy?

MATERIAL AND METHODS

In this study we reviewed the evidence-based practice pertaining to the outcome of surgery assisted infertility associated with endometriosis. Manuscripts published in PubMed and Science Direct as well as the bibliography cited in these articles were reviewed. Patients with peritoneal endometriosis with mild and severe disease were addressed separately. Patients who failed the primary surgery and managed by repeat or assisted reproduction technology were also evaluated. Patients who failed assisted reproduction and managed by surgery were also studied to determine of the best course of action.

RESULTS

In patients with minimal and mild pelvic endometriosis, excision or ablation of the peritoneal endometriosis increases the pregnancy rate. In women with severe endometriosis, controlled trials suggested an improvement of pregnancy rate. In women with ovarian endometrioma 4 cm or larger ovarian cystectomy increases the pregnancy rate, decreases the recurrence rate, but is associated with decrease in ovarian reserve. In patients who have failed the primary surgery, assisted reproduction appears to be significantly more effective than repeat surgery. In patients who failed assisted reproduction, the management remains to be extremely controversial. Surgery in expert hands might result in significant improvement in pregnancy rate.

CONCLUSION

In women with minimal and mild endometriosis, surgical excision or ablation of endometriosis is recommended as first line with doubling the pregnancy rate. In patients with moderate and severe endometriosis surgical excision also is recommended as first line. In patients who failed to conceive spontaneously after surgery, assisted reproduction is more effective than repeat surgery. Following surgery, the ovarian reserve may be reduced as determined by Anti Mullerian Hormone. The antral follicle count is not significantly reduced. In women with large endometriomas > 4 cm the ovarian endometrioma should be removed. In women who have failed assisted reproduction, further management remains controversial in the present time.

Completion thyroidectomy in differentiated thyroid cancer: When to perform?

OBJECTIVE

Completion thyroidectomy is recommended in patients who have been diagnosed with differentiated thyroid cancer on histopathological evaluation, if their first operation was a conservative approach. The critical issue is when to do the second operation.

MATERIAL AND METHODS

The medical records of 66 patients who underwent completion thyroidectomy for the treatment of differentiated thyroid cancer in our clinic between 2006-2013 were retrospectively analyzed. All data were compared after patients were divided into two groups according to the interval between the first surgery and completion thyroidectomy.

RESULTS

Fifty-two patients (78.8%) were women and 14 patients (21.2%) were male. Completion thyroidectomy was performed 10-90 days after the initial surgery (group 1) in 26 patients, whereas it was performed later than 90 days in 40 patients (group 2). Temporary hypoparathyroidism occurred in two patients (7.7%) in group 1, and in 3 patients (7.5%) in group 2. Transient recurrent laryngeal nerve palsy was observed in 1 patient (3.9%) in group 1, and in 1 patient (2.5%) in group 2. There were no permanent morbidities in both groups. Residual tumor rate after completion thyroidectomy was 45.5%. There was no statistically significant difference between the two groups in terms of complications after completion thyroidectomy.

CONCLUSION

Although in some studies it is recommended that completion thyroidectomy should be performed either before scar tissue development or after clinical remission of scar tissue, edema and inflammation, we believe that timing of surgery has no effect on morbidity.