Hasil untuk "Surgery"

A. D'cruz, R. Vaish, N. Kapre et al.

J. Douketis, A. Spyropoulos, F. Spencer et al.

Y. Bang, Young-Woo Kim, Han-Kwang Yang et al.

J. Wright, M. Swiontkowski, J. Heckman

P. Burns, Rod J. Rohrich, K. Chung

As the name suggests, evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Several papers published in Plastic Surgery journals concerning EBM topics have touched on this subject. 1–6 Specifically, previous papers have discussed the lack of higher level evidence in PRS and need to improve the evidence published in the journal. Before that can be accomplished, it is important to understand the history behind the levels and how they should be interpreted. This paper will focus on the origin of levels of evidence, their relevance to the EBM movement and the implications for the field of plastic surgery as well as the everyday practice of plastic surgery.

H. Kitchener, A. Swart, Q. Qian et al.

BACKGROUND Hysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease and as a therapeutic procedure; however, randomised trials need to be done to assess therapeutic efficacy. The ASTEC surgical trial investigated whether pelvic lymphadenectomy could improve survival of women with endometrial cancer. METHODS From 85 centres in four countries, 1408 women with histologically proven endometrial carcinoma thought preoperatively to be confined to the corpus were randomly allocated by a minimisation method to standard surgery (hysterectomy and BSO, peritoneal washings, and palpation of para-aortic nodes; n=704) or standard surgery plus lymphadenectomy (n=704). The primary outcome measure was overall survival. To control for postsurgical treatment, women with early-stage disease at intermediate or high risk of recurrence were randomised (independent of lymph-node status) into the ASTEC radiotherapy trial. Analysis was by intention to treat. This study is registered, number ISRCTN 16571884. FINDINGS After a median follow-up of 37 months (IQR 24-58), 191 women (88 standard surgery group, 103 lymphadenectomy group) had died, with a hazard ratio (HR) of 1.16 (95% CI 0.87-1.54; p=0.31) in favour of standard surgery and an absolute difference in 5-year overall survival of 1% (95% CI -4 to 6). 251 women died or had recurrent disease (107 standard surgery group, 144 lymphadenectomy group), with an HR of 1.35 (1.06-1.73; p=0.017) in favour of standard surgery and an absolute difference in 5-year recurrence-free survival of 6% (1-12). With adjustment for baseline characteristics and pathology details, the HR for overall survival was 1.04 (0.74-1.45; p=0.83) and for recurrence-free survival was 1.25 (0.93-1.66; p=0.14). INTERPRETATION Our results show no evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early endometrial cancer. Pelvic lymphadenectomy cannot be recommended as routine procedure for therapeutic purposes outside of clinical trials.

I. Learmonth, Claire Young, C. Rorabeck

Minshan Chen, Jin-qing Li, Yun Zheng et al.

E. Chaikof, J. Blankensteijn, P. Harris et al.

Isabelle Flammang, Ann-Kathrin Eichelmann, Sebastian Schäfer et al.

Abstract Deep infiltrating endometriosis (DIE) often affects the bowel and may necessitate colorectal resection. While protective ileostomy can reduce complications, it carries relevant morbidity. This study evaluates endoscopic complication management and long-term outcome of patients treated at a certified surgical endoscopy and endometriosis center. All patients undergoing interdisciplinary surgery for DIE (2015–2024) were retrospectively included. Preoperative sigmoidoscopy and postoperative endoscopic evaluation of anastomoses were performed routinely. Surgical approaches included shaving, excision or resection with/without ileostomy. Surgical complications, such as anastomotic leakages and stenoses, were primarily managed endoscopically. 118 women (median age: 33 years) underwent surgery: rectal shaving (25%), sigmoid (6%) and rectal resection (69%). Median anastomotic height was 10 cm, 44% received a protective ileostomy. Anastomotic leakage (8%) and stenosis (9%) were successfully managed endoscopically. Recurrence requiring reoperation occurred in 41% after shaving vs. 27% after resection. Ileostomy reversal was achieved in all cases. Postoperative continence was acceptable (LARS median: 13). General health (EQ-5D-5 L: median 70) was good at a median follow-up of 75 months. 84% would choose surgical treatment again. Colorectal resection for DIE can achieve favorable long-term outcomes in a structured interdisciplinary setting. Proactive endoscopic management supports bowel continuity despite complications. Prospective studies are needed to validate outcomes and refine patient selection.

Roberto Eleopra, Marcello Esposito, Anna Rita Bentivoglio et al.

Cervical dystonia (CD) is the most common adult-onset focal dystonia, with heterogeneous clinical presentation and significant functional impairment. Currently, no structured Italian good clinical practice documents specifically addressing CD have been published. Optimizing CD management requires expert-based recommendations to guide diagnosis, treatment, and follow-up. A two-round Delphi process was conducted, involving a scientific board of six neurologists with expertise in CD management and an external panel of 56 Italian experts (neurologists and physiatrists managing CD patients). Fifty-two statements were developed, discussed, and voted using a 5-point Likert scale, with consensus defined as ≥75% agreement (‘strongly agree’ or ‘somewhat agree’). In Round 1, 48 of 52 statements (92.4%) reached consensus; the four remaining statements were revised, and two were re-voted in Round 2, both achieving consensus. Final recommendations emphasize comprehensive patient assessment in multiple postural conditions; individualized botulinum neurotoxin type A (BoNT-A) dosing taking into account tonic and phasic components, pain, and dysphagia; the use of instrumental guidance; standardized outcome measures; and integration of physiotherapy and psychological support. This article provides structured good clinical practice recommendations for CD management and offers clinicians, especially those with limited experience, a practical framework to standardize care, optimize treatment, and improve patient outcomes.

Caitlin W. Hicks

Caitlin W. Hicks, Steven D. Wexner

Mara Koelker, Sandra Trepte, Jakob Klemm et al.

Background and objective: Radical cystectomy (RC) in bladder cancer patients is associated with considerable short-term morbidity. Although RC is known to impair health-related quality of life (HRQOL), the impact of complication severity on HRQOL in the long term remains unclear. The aim of this study is to investigate the relationship between perioperative cumulative complication burden and HRQOL after RC using data from a prospective registry, given the limited existing evidence. Methods: The Comprehensive Outcome Measures and Perioperative Morbidity After CystecTomy (COMPACT) registry (DRKS00024929) prospectively collects standardized data on perioperative morbidity and longitudinal patient-reported outcome measures. The study includes patients undergoing open RC with pelvic lymph node dissection and urinary diversion for bladder cancer. According to the European Association of Urology guidelines, 90-d morbidity was assessed using both the Clavien-Dindo classification (CDC) and the Comprehensive Complication Index (CCI). HRQOL was measured at baseline and 3, 6, and 12 mo using the Functional Assessment of Cancer Therapy—Bladder—Cystectomy (FACT-BL-CYS) scores (range 0–168). Patients treated between 2020 and 2022 were included. Multivariable linear regression was used to evaluate the associations of 90-d CDC grade ≥IIIb (ie, “major complications”) and 90-d CCI with the 6-mo FACT-BL-CYS total score, adjusting for clinical and pathological confounders. Key findings and limitations: Among 82 patients, one (1.2%) had no complications, and 47 (57%) had CDC grade ≤II, 22 (27%) grade III, and 11 (13%) grade IV complications. The 90-d mortality rate was 1.2%. The median 90-d CCI was 35 (interquartile range [IQR] 26–45). The median 6-mo FACT-BL-CYS total score was 119 (IQR 90–142). Only comorbidity (age-adjusted Charlson index) was significantly associated with HRQOL (coefficient: –4.76, p = 0.02); neither CDC ≥IIIb (p = 0.7) nor CCI (p = 0.2) was significant. Limitations include uncertainty in effect sizes due to the low number of major complications. Conclusions and clinical implications: Open RC is associated with a high rate of perioperative complications when assessed with standardized methods. However, our findings suggest that their impact on HRQOL at 6 mo is limited. HRQOL appears to be more closely related to age-adjusted comorbidity. These insights should inform preoperative counseling and guide individualized postoperative care planning. Patient summary: We looked at whether complications after bladder removal surgery (radical cystectomy) affect patients’ quality of life. We found that most patients have complications, but these usually do not reduce quality of life 6 mo after surgery. Instead, pre-existing health conditions had a stronger impact on recovery.

Sheila Souza de Sales, Angélica Cardoso Martins, Leonardo Montenegro Matos Albuquerque et al.

Smit Bharat Solanki, Vineet V. Mishra, Arminder Singh Dhiman

BACKGROUND: Three-dimensional (3D) high-definition (HD) laparoscopy is a promising tool in minimally invasive gynecologic surgery, offering enhanced depth perception and visualization. However, its role in total laparoscopic hysterectomy (TLH), particularly in patients with varying body mass index (BMI), remains underexplored. OBJECTIVE: To evaluate the impact of 3D HD laparoscopy on surgical efficiency and patient outcomes in TLH, with a focus on BMI-related differences. DESIGN AND SETTINGS: A single-center retrospective study PATIENTS AND METHODS: Sixty patients who underwent TLH were included: n=30 used 3D HD laparoscopy (Aesculap 3D EinsteinVision) and n=30 matched controls used 2D laparoscopy. Matching criteria included uterine weight and prior surgical history. Patients were stratified according to BMI (≤24.9, 25–29.9, ≥30.0 kg/m2). MAIN OUTCOME MEASURES: Operative time, vault suturing time, blood loss, trocar site incisions, haemoglobin drop, and complication rates. SAMPLE SIZE: 60 patients (30 in each group) RESULTS: The 3D HD laparoscopy group demonstrated significant improvements across multiple outcomes. Trocar site incisions were significantly reduced in all BMI categories (P <.001). Vault suturing time was shorter in the 3D HD laparoscopy group (P =.002), and total operative time was reduced in overweight patients (P =.015). Obese patients in the 3D group had lower haemoglobin drop (P =.01) and reduced blood loss compared to 2D laparoscopy group (P =.017). CONCLUSION: 3D HD laparoscopy enhances surgical efficiency in TLH, especially in patients with higher BMI, by minimizing trocar site incisions, reducing vault suturing times, and improving hemostasis—highlighting its value in overcoming challenges of minimally invasive gynecologic surgery. LIMITATIONS: The study's retrospective design and modest sample size limit generalizability.

Yuxin Zhang, Xiaoyu Liao, Dahe Zhang et al.

Background: Temporomandibular disorder (TMD) is the most common maxillofacial musculoskeletal disease involving various conditions such as chewing muscle disorders, disc displacement and osteoarthritis. However, its intricate pathogenesis remains unclear. Herein, by integrating evidence at the blood, tissue and cell levels, we aimed to investigate the association of cell death-related genes with TMD and predict potential target drugs. Methods: Summary-level data on methylation, expression and protein abundance levels of cell death-related genes were used to identify drug-targeted genes at the blood level. FUSION tool was employed to identify and validate associations at the tissue level. Single-cell analysis was utilised to determine whether TMD-associated cell death genes exhibited higher expression in specific cell types. Drug prediction and molecular docking was used to confirm drug-related effects of TMD-associated cell death genes. Results: Integrating the overlapping results of summary-data-based Mendelian randomisation of mQTL, eQTL and pQTL at the blood level with Bayesian co-localisation analysis, 3 cell death-related genes were identified as causally associated with TMD: TIE1 (Tier 1), IFI16 (Tier 1) and GATM (Tier 2). Based on tissue-level FUSION analysis, we validated the specific effects of TIE1 and GATM genes in muscle-skeletal histology. Meanwhile, single-cell data were utilised to further analyse the cell type-specific enrichment of the 3 target genes in TMD. Finally, drug prediction and molecular docking identified 5 pharmacokinetic associations of 3 TMD-associated cell death genes. Conclusion: Based on multilevel evidence of the blood, tissue and cell, we found that cell death-related genes TIE1, IFI16 and GATM were associated with TMD risk and predict potential target drugs such as fostamatinib. This study further elucidates the critical role of cell death-related molecules and drugs in TMD.

Jung Yeol Seo, Seung Hyun Kim, Jae Woo Lee et al.

Background Implant-based immediate breast reconstruction surgery with nipple-sparing mastectomy has recently been favored by patients. However, in patients who do not wish to undergo balancing procedures, it is difficult to select the appropriate implant size, making it challenging to achieve a symmetrical breast shape. Therefore, this study investigated the differences in breast asymmetry and other complications in patients who underwent a two-stage procedure or direct-to-implant (DTI) breast reconstruction to determine whether the two-stage procedure can produce more favorable outcomes. Methods The participants of this study were patients who underwent immediate two-stage breast reconstruction or DTI breast reconstruction from May 2018 to April 2022, did not receive postoperative radiotherapy, and did not wish to undergo any balancing procedures. An acellular dermal matrix was used for breast reconstruction in all patients, and a single reconstructive surgeon performed all the operations. Statistical significance was set at P<0.05. Results No significant differences in complications were found between the patients who underwent DTI breast reconstruction and those who underwent two-stage breast reconstruction. In the two-stage breast reconstruction group, breast volume asymmetry was observed in 18.4% (seven patients), which was significantly lower than the percentage of 44.7% (17 patients) observed in the DTI group. Conclusions Breast asymmetry was observed in a significant proportion of the patients in both groups. However, because breast volume asymmetry was more common in the DTI group than in the two-stage breast reconstruction group, two-stage breast reconstruction may be a favorable method for patients who do not wish to undergo balancing procedures.

Jagmeet S. Arora, BS, Joshua K. Kim, BS, Mikhail Pakvasa, MD et al.

Background:. Approximately 20% of retained foreign bodies are surgical needles. Retained macro-needles may become symptomatic, but the effect of microsurgical needles is uncertain. We present the first animal model to simulate microsurgical needle retention. Given a lack of reported adverse outcomes associated with macro-needles and a smaller cutting area of microsurgical needles, we hypothesized that microsurgical needles in rats would not cause changes in health or neurovascular compromise. Methods:. Male Sprague-Dawley rats (x̄ weight: 288.9 g) were implanted with a single, 9.0 needle (n = 8) or 8.0 needle (n = 8) orthogonal to the right femoral vessels and sutured in place. A control group (n = 8) underwent sham surgery. Weekly, a cumulative health score evaluating body weight, body condition score, physical appearance, and behavior for each rat was determined. Infrared thermography (°C, FLIR one) of each hindlimb and the difference was obtained on postoperative days 15, 30, 60, and 90. On day 90, animals were euthanatized, hindlimbs were imaged via fluoroscopy, and needles were explanted. Results:. The mean, cumulative health score for all cohorts at each weekly timepoint was 0. The mean temperature difference was not significantly different on postoperative days 15 (P = 0.54), 30 (P = 0.97), 60 (P = 0.29), or 90 (P = 0.09). In seven of eight rats, 8.0 needles were recovered and visualized on fluoroscopy. In six of eight rats, 9.0 needles were recovered, but 0/8 needles were visualized on fluoroscopy. Conclusions:. Microsurgical needle retention near neurovascular structures may be benign, and imaging for needles smaller than 8.0 may be futile. Further studies should explore microsurgical needle retention potentially through larger animal models.

Fan Bai, Lu Liu, Qipei Wei et al.