Search Results (58)

Background/Objectives: The optimal surgical management of perforated gastric cancer (PGC) in emergency settings remains controversial. Urgent upfront one-stage gastrectomy (1SG) and two-stage gastrectomy (2SG) with damage-control surgery followed by elective gastrectomy have been proposed. The aim of the present systematic review is to compare short- and long-term outcomes between 1SG and 2SG in the treatment of PGC. Methods: A systematic review and individual patient data (IPD) meta-analysis of studies reporting data of patients undergoing 1SG vs. 2SG for PGC was conducted. The time-dependent effects of surgical interventions were assessed using a likelihood ratio test. Hazard function plots were generated via marginal prediction. Results: Ten retrospective series (579 patients) were included. Overall, 482 patients (83%) underwent 1SG, while 97 patients (17%) were treated with 2SG. A trend toward better short-term oncological outcomes and safety profiles for 2SG compared to 1SG was observed. Long-term outcomes were comparable between 1SG and 2SG, and the IPD meta-analysis showed no statistically significant difference between the two approaches in terms of OS or hazard for mortality at all time points. A trend towards a higher hazard for mortality was observed for 1SG in the first 20 months postoperatively. Conclusions: Our analysis suggests that 1SG and 2SG yield comparable short-term outcomes, although 2SG may be associated with a lower medium-term mortality risk. Further research is needed to identify key factors to improve clinical judgments and decision-making in PGC. Full article

Objectives: Esophagectomy is a central component of surgical treatment for esophageal cancer, with both one- and two-stage procedures frequently employed. However, these procedures are associated with a high rate of postoperative complications. This study aimed to assess the rates and types of complications following one- and two-stage esophagectomies, and to identify predictors of adverse outcomes in patients with esophageal cancer. Methods: We analyzed clinical data from patients undergoing one-stage (Ivor Lewis) or two-stage esophagectomies. Postoperative complications were defined as events occurring within 30 days after surgery. Variables such as patient demographics, clinical staging, histological tumor grade, and neoadjuvant chemoradiotherapy were assessed for their association with complications. Statistical analyses included logistic regression and chi-squared tests. Results: Among 61 patients, postoperative complications occurred in 24.6% of cases. The most frequent were pneumonia (22.2%), anastomotic leakage (22.2%), and hemothorax (27.8%). Significant predictors of complications included intraoperative disease staging, histological tumor grade, and the use of neoadjuvant chemoradiotherapy. The odds ratio for complications following neoadjuvant chemoradiotherapy was 8.75. The frequency of anastomotic leakage was similar in one- and two-stage procedures (30.8% vs. 26.3%, respectively). Conclusions: Postoperative complications remain a significant challenge in esophageal cancer surgery, particularly in the context of advanced disease or neoadjuvant chemoradiotherapy. These findings underscore the necessity for precise surgical planning and comprehensive postoperative care to mitigate risks and optimize patient outcomes. While postoperative risk is high, it is primarily driven by tumor characteristics and preoperative therapy. Full article

Background/Objectives: Traditional treatment for chronic osteomyelitis is temporary implantation of antibiotic-impregnated cement beads, followed by bone grafting after the infection is controlled. In this way, a staged operation is needed, and undergoing repetitive general anesthesia is a burden. Moreover, damage to the soft tissue at the surgical site due to several incisions is a concern. This study was conducted to investigate the outcomes of one-stage antibiotic-mixed cement blocks, instead of beads, used as a primary salvage procedure to treat chronic osteomyelitis of the foot, ankle, and lower leg. Methods: Twenty patients with chronic osteomyelitis of the leg and foot were included. They underwent complete debridement of the infected bone, and antibiotic-mixed cement fillings were placed into the defected bone space. Full-weight-bearing activities were allowed immediately after surgery. Results: For 16 of the 18 patients, infection was controlled after one-time surgery. Repeat antibiotic cement-filling surgery was necessary for two patients. Two-staged surgery with continuous irrigation and cement filling was necessary for one large tibial lesion. Conversion into arthrodesis of the metatarsophalangeal joint was necessary for metatarsal head infection. Conclusions: One-stage surgery with complete debridement and antibiotic-mixed cement filling is a simple and effective procedure for treating intractable chronic osteomyelitis, which makes full-weight-bearing walking possible immediately after surgery. Full article

Background: The relationship between dental implants and sinus mucoceles is an area of growing interest in oral and maxillofacial surgery, as therapeutic approaches for these conditions remain controversial. This case report presents a 48-year-old male with no significant medical history who sought dental care due to recurrent abscesses on the distal abutment of a five-unit maxillary bridge. Clinical and radiographic evaluations, including Cone-Beam Computed Tomography (CBCT), revealed a pathologic lesion associated with the second molar, insufficient alveolar bone height in the posterior maxilla, and a radiopaque mass on the sinus floor. Methods: A one-stage surgical approach was planned, involving the second molar extraction, the sinus cyst removal, sinus floor elevation, and simultaneous implant placement. The prosthetic restoration was completed six months postoperatively. Results: Over an 88-month follow-up period, no prosthetic complications were observed, and the patient reported high satisfaction with the restoration’s function and aesthetics. Conclusions: This case highlights a single-stage surgical strategy’s feasibility and long-term success in managing asymptomatic maxillary sinus mucoceles while optimizing implant placement and rehabilitation. Full article

The aim of this review is to investigate the effective role of local antimicrobial protection for one-stage cemented and cementless hip revision surgery. Twelve studies reporting the results of cemented single-stage procedures with a minimum two-year follow-up were reviewed. When pooling together the data, no infection recurrence was observed on average in 83.3% of the patients (a range of 75.0% to 100%). Only two papers included patients treated without the use of antibiotic-loaded bone cement, with an average infection control of 95.9% in a total of 195 patients. This figure appears to be better than the 80.7% infection control obtained by pooling together all the remaining studies. Concerning cementless one-stage revision, a total of 17 studies, reporting on 521 patients, showed an average of 90.0% (range 56.8% to 100%) no infection recurrence at a minimum two-year follow-up. No comparative study investigated cementless revision with or without local antibacterial protection. The pooled data showed an average infection control of 86.7%, without the application of local antibacterials, compared to 90.1% to 100% with local antimicrobial protection, depending on the technology used. No statistical difference could be found, either considering local antibacterial strategies alone or pooled together. No side effects had been reported by any local antibacterial technique. Local antibacterial protection for one-stage hip revision surgery, although safe and largely performed in the clinical setting, appears to still rely mainly on experts’ opinions with no prospective or comparative trial, hence no definitive conclusion can be drawn concerning its effective role in one-stage hip revision surgery. Full article

Purpose: Facial paralysis results from congenital or acquired facial nerve damage, leading to significant cosmetic and functional deficits. Surgical resection of parotid and midface tumors can cause facial paralysis, necessitating effective treatment strategies. This review addresses the challenge of restoring movement and function in late-stage facial paralysis, focusing on dynamic repair techniques involving nerve and muscle transplantation. Methods: The review encompasses studies on dynamic repair surgery for late facial paralysis, including techniques such as local muscle flap with pedicle transfer, vascularized nerve flap with pedicle transfer, and multiple muscle flap procedures. A systematic literature search was conducted using PubMed, Web of Science, and Google Scholar, covering studies from 2000 to 2024. Keywords included “dynamic repair”, “late-stage facial paralysis”, “nerve and muscle transplantation”, “muscle flap”, and “tendon transposition”. Included were clinical studies, systematic reviews, and meta-analyses reporting surgical outcomes. Exclusion criteria included studies with insufficient data and non-peer-reviewed articles. Results: Dynamic repair techniques involving nerve and muscle transplantation are essential for treating late-stage facial paralysis. Each surgical method has strengths and limitations. The masseter muscle flap demonstrates high success rates, although it can cause horizontal tension and jaw contour issues. The temporalis muscle flap is effective for smile restoration but may lead to temporal concavity. The gracilis muscle flap is widely used, especially with dual nerve innervation, showing high success in spontaneous smiles but requiring a longer recovery period. The latissimus dorsi flap is effective but can cause edema and shoulder issues. The serratus anterior free flap offers flexibility with precise vector positioning but may not achieve adequate lip elevation and can cause cheek swelling. Combined multi-flap surgeries provide more natural facial expressions but increase surgical complexity and require advanced microsurgical skills. Conclusions: Dual nerve innervation shows promise for restoring spontaneous smiles. One-stage surgery offers faster recovery and reduced financial burden. Comprehensive patient evaluation is crucial to select the most suitable surgical method. Dynamic repair techniques involving nerve and muscle transplantation provide effective solutions for restoring function and aesthetics in late-stage facial paralysis. Future research should focus on long-term outcomes, patient satisfaction, and standardizing surgical protocols to optimize treatment strategies. Full article

Objective: In this paper, we share our single-center experience of successful multidisciplinary management of patients with Alagille syndrome. In addition, we aim to highlight the need for an Alagille program for effectively managing these patients, in general, and particularly peripheral pulmonary artery stenosis associated with this syndrome. Study Design: This is a retrospective review of six children with Alagille syndrome and advanced liver involvement who underwent pulmonary artery reconstruction between 2021 and 2022. Cardiac diagnosis, co-existing liver disease burdens, management approach, and short-term outcomes were analyzed. Results: All the patients underwent one-stage extensive bilateral branch pulmonary rehabilitation. Concomitant procedures included repair of tetralogy of Fallot in one patient and repair of supravalvar pulmonary artery stenosis in two. One patient had balloon pulmonary branch angioplasty before surgery. In all patients, there was a decrease in right ventricular systolic pressure post-operatively. Three patients underwent liver transplantation for pre-existing liver dysfunction. At a median 3-year follow-up, all the patients were alive with their right ventricular systolic pressure less than half of their systemic systolic pressure. One patient underwent balloon angioplasty due to new and recurrent left pulmonary artery stenosis 13 months after surgery. Conclusion: Pulmonary arteries can be successfully rehabilitated surgically in the presence of complex branch disease. Patients with advanced liver disease can undergo successful complex pulmonary artery reconstruction, which can facilitate their future liver transplantation course. A multidisciplinary team approach is a key for successful management of Alagille patients. Full article

Background and Purpose: In urological surgery, accurate localization of the ureteral orifice is crucial for procedures such as ureteral stent insertion, assessment of ureteral orifice lesions, and prostate tumor resection. Consequently, we have developed and validated a computer-assisted ureteral orifice detection system that combines the YOLO deep convolutional neural network and the attention mechanism. Data: The cases were partitioned into a training set and a validation set at a 4:1 ratio, with 84 cases comprising 820 images in the training set and 20 cases containing 223 images in the validation set. Method: We improved the YOLO network structure to accomplish the detection task. Based on the one-stage strategy, we replaced the backbone of YOLOv5 with a structure composed of ConvNeXt blocks. Additionally, we introduced GRN (Global Response Normalization) modules and SE blocks into the blocks to enhance deep feature diversity. In the feature enhancement section, we incorporated the BiFormer attention structure, which provides long-distance context dependencies without adding excessive computational costs. Finally, we improved the prediction box loss function to WIoU (Wise-IoU), enhancing the accuracy of the prediction boxes. Results: Testing on 223 cystoscopy images demonstrated a precision of 0.928 and recall of 0.756 for our proposed ureteral orifice detection network. With an overlap threshold of 0.5, the mAP of our proposed image detection system reached 0.896. The entire model achieved a single-frame detection speed of 5.7 ms on the platform, with a frame rate of 175FPS. Conclusion: We have enhanced a deep learning framework based on the one-stage YOLO strategy, suitable for real-time detection of the ureteral orifice in endoscopic scenarios. The system simultaneously maintains high accuracy and good real-time performance. This method holds substantial potential as an excellent learning and feedback system for trainees and new urologists in clinical settings. Full article

Aim: Periprosthetic joint infections (PJIs) of unicompartmental knee arthroplasties (UKAs) can lead to secondary osteoarthritis of the other compartments. The objective of this study was to identify the frequency of PJIs in cases of UKA with progressed secondary osteoarthritis and the result of septic one-stage revision in these cases to verify the value of preoperative aspiration in cases of secondary osteoarthritis of UKA. Methods: We retrospectively reviewed 97 patients with a unicompartmental arthroplasty who underwent revision surgery to a total knee arthroplasty (TKA) between January 2013 and March 2021 because of subsequent osteoarthritis. Preoperative aspiration and sample collection during the revision surgery were employed to identify potential periprosthetic joint infections (PJIs). The post-revision period was monitored for septic complications over an average duration of 55.7 ± 25.2 months (24–113). Results: PJIs were identified in 5.2% of cases through preoperative aspiration. In all instances of PJIs, a one-stage septic revision was performed, and notably, none of these cases experienced septic complications during the follow-up period. Conclusions: Preoperative aspiration is essential in order to exclude the presence of a PJI before performing revision surgery of UKA due to secondary osteoarthritis. Full article

Introduction: Hirschsprung disease (HD) manifests as a developmental anomaly affecting the enteric nervous system, where there is an absence of ganglion cells in the lower part of the intestine. This deficiency leads to functional blockages within the intestines. HD is usually confirmed or ruled out through rectal biopsy. The identification of any ganglion cells through hematoxylin and eosin (H&E) staining rules out HD. If ganglion cells are absent, further staining with acetylcholine-esterase (AChE) histochemistry or calretinin immunohistochemistry (IHC) forms part of the standard procedure for determining a diagnosis of HD. In 2017, our Institute of Pathology at University Hospital of Heidelberg changed our HD diagnostic procedure from AChE histochemistry to calretinin IHC. In this paper, we report the impact of the diagnostic procedure change on surgical HD therapy procedures and on the clinical outcome of HD patients. Methods: We conducted a retrospective review of the diagnostic procedures, clinical data, and postoperative progress of 29 patients who underwent surgical treatment for HD in the Department of Pediatric Surgery, University of Heidelberg, between 2012 and 2021. The patient sample was divided into two groups, each covering a treatment period of 5 years. In 2012–2016, HD diagnosis was performed exclusively using AChE histochemistry (AChE group, n = 17). In 2017–2021, HD diagnosis was performed exclusively using calretinin IHC (CR group, n = 12). Results: There were no significant differences between the groups in sex distribution, weeks of gestation, birth weight, length of the aganglionic segment, or associated congenital anomalies. Almost half of the children in the AChE group, twice as many as in the CR group, required an enterostomy before transanal endorectal pull-through procedure (TERPT). In the AChE group, 4 patients (23.5%) required repeat bowel sampling to confirm the diagnosis. Compared to the AChE group, more children in the CR group suffered from constipation post TERPT. Discussion: Elevated AChE expression is linked to hypertrophied extrinsic cholinergic nerve fibers in the aganglionic segment in the majority of patients with HD. The manifestation of increased AChE expression develops over time. Therefore, in neonatal patients with HD, especially those in the first 3 weeks of life, an increase in AChE reaction is not detected. Calretinin IHC reliably identifies the presence or absence of ganglion cells and offers multiple benefits over AChE histochemistry. These include the ability to perform the test on paraffin-embedded tissue sections, a straightforward staining pattern, a clear binary interpretation (negative or positive), cost-effectiveness, and utility regardless of patient age. Conclusions: The ability of calretinin IHC to diagnose HD early and time-independently prevented repeated intestinal biopsies in our patient population and allowed us to perform a one-stage TERPT in the first months of life, reducing the number of enterostomies and restoring colonic continuity early. Patients undergoing transanal pull-through under the age of 3 months require a close follow-up to detect cases with bowel movement problems. Full article

Periprosthetic joint infections (PJIs) are a prominent subject of discussion in orthopedics and are frequently debated at conferences and congresses. In the context of PJIs affecting the knee, the decision between following a one-stage or two-stage treatment approach has historically been a pivotal consideration. The first option is limited by indications and potentially devastating complications in case of failure, whereas the second is widely accepted as the gold standard. Initially, the spacer was conceived solely to restore and maintain knee space after removal of the implant. An articulating spacer was introduced to mitigate patient limitations and improve knee function and quality of life. Two main types of articulating spacers are utilized in knee PJI treatment: the mold spacer and the metal-on-poly spacer. This text outlines a technique for metal-on-poly spacer implants. Based on our experience and the existing literature, this approach facilitates early full weight bearing and faster recovery of the knee’s range of motion, ultimately improving the quality of life after surgery, thus allowing the spacer retention for an extended period, as suggested by the 1.5-stage revision. Full article

Background: Short implants have been used in the restoration of edentulous jaws in the past several years. However, some studies have suggested that short implants are less successful than standard implants. The aim of this study is to investigate the outcome of short implants placed in the posterior maxilla or mandible following one-stage or immediate-function protocols with a follow-up of 7 years (clinically) and 5 years (radiographically). Methods: This study included 127 patients rehabilitated with 217 implants measuring 7 mm and supporting 157 fixed prostheses in the posterior segments of both jaws. Final abutments were delivered at the surgery stage and were loaded after 4 months in 116 patients (199 implants). The primary outcome measure was implant survival measured through life tables. Secondary outcome measures were marginal bone loss and the incidence of biological and mechanical complications at the patient level and implant level (evaluated through descriptive statistics). Results: Twenty-four patients (18.9%) with 45 implants (20.7%) were lost to the follow-up. In total, 32 implants failed (14.8%) in 22 patients (17.3%), resulting in a cumulative survival rate at 7 years of 81.2% for 7 mm implants in the rehabilitation of the posterior regions of the maxilla and mandible. The average (standard deviation) marginal bone loss was 1.47 mm (0.99 mm) at 5 years. The incidence rate of biological complications was 12.6% and 10.6% at the patient and implant levels, respectively. The incidence rate of mechanical complications was 21.3% for patients and 16.1% for implants. A higher failure rate was registered in smokers and in implant arrangements with a sequence of three fixtures in proximity. Conclusions: Within the limitations of this study, it can be concluded that the placement of 7 mm long implants for the partial implant-supported rehabilitation of atrophic posterior jaws is possible in the long term, judging by the survival rate and stable average marginal bone loss. Nevertheless, strict case selection should be performed, especially in smokers and with implant arrangements that provide a minimum of one unit in inter-implant distance. Full article

Background/Objectives: The need for surgical reconstruction of scalp defects following the excision of cutaneous skin cancers is an increasingly common procedure. Particular challenges arise when considering options for reconstruction of large defects not amenable to local skin flap coverage. The use of skin grafts poses the risk of donor site morbidity. This paper investigates the emerging use of Integra^®, a synthetic acellular dermal regeneration template, as an alternative or adjunct to skin grafting in scalp reconstruction. Methods: The study presents a retrospective analysis of 101 patients who underwent Integra^®-based reconstruction of scalp defects. Demographics, procedure details, complications, need for further surgery, and time to healing were evaluated. Results: The overall success rate of the one-stage Integra^®-only procedure was 95%, with a minor complication rate of 30.7%. Anticoagulation medication was identified as an independent risk factor for post-operative infection, while previous head and neck radiotherapy and increased defect depth were associated with the requirement for a second-stage skin graft. Conclusions: These findings support the consideration of Integra^® as a safe and viable alternative for both partial and full thickness scalp defects in a select cohort of complex highly co-morbid patients, reducing complications and the need for additional procedures. Full article

Background and Objectives: Adolescent idiopathic scoliosis (AIS) is a prevalent three-dimensional spinal disorder, with a multifactorial pathogenesis, including genetics and environmental aspects. Treatment options include non-surgical and surgical treatment. Surgical interventions demonstrate positive outcomes in terms of deformity correction, pain relief, and improvements of the cardiac and pulmonary function. Surgical complications, including excessive blood loss and neurologic deficits, are reported in 2.27–12% of cases. Navigation-assisted techniques, such as the O-arm system, have been a recent focus with enhanced precision. This study aims to evaluate the results and complications of one-stage posterior instrumentation fusion in AIS patients assisted by O-arm navigation. Materials and Methods: This retrospective study assesses 55 patients with AIS (12–28 years) who underwent one-stage posterior instrumentation correction supported by O-arm navigation from June 2016 to August 2023. We examined radiological surgical outcomes (initial correction rate, loss of correction rate, last follow-up correction rate) and complications as major outcomes. The characteristics of the patients, intraoperative blood loss, operation time, number of fusion levels, and screw density were documented. Results: Of 73 patients, 55 met the inclusion criteria. The average age was 16.67 years, with a predominance of females (78.2%). The surgical outcomes demonstrated substantial initial correction (58.88%) and sustained positive radiological impact at the last follow-up (56.56%). Perioperative complications, including major and minor, occurred in 18.18% of the cases. Two patients experienced a major complication. Blood loss (509.46 mL) and operation time (402.13 min) were comparable to the literature ranges. Trend analysis indicated improvements in operation time and blood loss over the study period. Conclusions: O-arm navigation-assisted one-stage posterior instrumentation proves reliable for AIS corrective surgery, achieving significant and sustained positive radiological outcomes, lower correction loss, reduced intraoperative blood loss, and absence of implant-related complications. Despite the challenges, our study demonstrates the efficacy and maturation of this surgical approach. Full article

Prosthetic joint infection (PJI) is the most common mode of failure of megaprostheses, yet the literature on the topic is scarce, and studies report conflicting data regarding the optimal treatment strategy. Patients with megaprostheses PJI are often immunosuppressed, and surgeons must balance the trade-off between treatment efficacy and morbidity associated with the surgery aiming for infection eradication. Our review on megaprostheses PJI focuses on two axes: (1) risk factors and preventative strategies; and (2) surgical strategies to manage this condition. Risk factors were classified as either unmodifiable or modifiable. Attempts to decrease the risk of PJI should target the latter group. Strategies to prevent PJI include the use of silver-coated implants, timely discontinuation of perioperative antibiotic prophylaxis, and adequate soft tissue coverage to diminish the amount of dead space. Regarding surgical treatment, main strategies include debridement, antibiotics, implant retention (DAIR), DAIR with modular component exchange, stem retention (DAIR plus), one-stage, and two-stage revision. Two-stage revision is the “gold standard” for PJI in conventional implants; however, its success hinges on adequate soft tissue coverage and willingness of patients to tolerate a spacer for a minimum of 6 weeks. DAIR plus and one-stage revisions may be appropriate for a select group of patients who cannot endure the morbidity of two surgeries. Moreover, whenever DAIR is considered, exchange of the modular components should be performed (DAIR plus). Due to the low volume of megaprostheses implanted, studies assessing PJI should be conducted in a multi-institutional fashion. This would allow for more meaningful comparison of groups, with sufficient statistical power. Level of evidence: IV. Full article