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Minimally invasive mitral valve surgery (MIMVS) has become the standard approach for mitral valve pathology in many centres. The anterolateral mini thoracotomy access is beneficial in reoperative surgery by avoiding repeat sternotomy associated risks. The aim of this study is to analyse the safety of this technique. All patients undergoing reoperative MIMVS between 2008 and 2019 were studied retrospectively. Primary endpoint was 30-day major complications and mortality; secondary outcome was long term survival, reoperation rate and rate of more than moderate recurrent regurgitation. 146 Patients underwent reoperative MIMVS with a mean age of 68 ± 8 years. The composite outcome of 30-day major complication and mortality was 29.5%. 30-Day mortality was 6.2% and stroke rate 3.4%. Survival for the whole cohort was 89.7 ± 2.5% at 1-year, 71.6 ± 4.3% at 5 year and 50.9 ± 5.9% at 8-year follow up. Cox regression analysis revealed reduced left ventricular function (HR 2.8; 95%CI 1.5 - 5.0), GFR < 60 (HR 2.1; 95%CI 1.2 - 3.7) and active endocarditis (HR 6.4; 95%CI 2.7 - 15.4) as variables associated with reduced long-term survival. The cumulative incidence of re-operation after mitral valve replacement was 11.3 ± 3.2% at 5-year and for repair 16.2 ± 7.5% at 5-year. The cumulative incidence of more than moderate recurrent regurgitation after mitral valve repair was 25.4 ± 9.0% at 3-year. Minimally invasive access in reoperative mitral valve surgery in the current study showed similar 30-day mortality and stroke rate compared to repeat sternotomy results reported in literature. [ABSTRACT FROM AUTHOR]

About 3% of primary pyeloplasties may require a re-do pyeloplasty for recurrent uretero pelvic junction obstruction (UPJO) making it an uncommon operation even in large volume centers. In this MA we have compared the outcomes of open (OP), laparoscopic (LP) and robot assisted LP (RALP) approaches in managing recurrent UPJO. Pubmed/Index medicus etc. were searched for re-do pyeloplasty (Open OR Laparoscopic OR Robot-assisted) AND (Redo OR Reoperative OR failed) AND (child OR pediatric OR paediatric), for articles published between 2001 and 2021. Duplicate publications were identified and removed. Articles with grossly incomplete data and errors in reporting were excluded, as were articles reporting <5 cases. The systematic review was carried out according to PRISMA guidelines and meta-analysis of proportions was carried out using MetaXL 5.3. A total of 18 articles on re-do pyeloplasty were included in the analysis. In total, there were 87, 77 and 123 redo pyeloplasties in OP, LP and RALP groups respectively. The I2 statistics for OP, LP and RALP showed low heterogeneity with I2 of 24%, 0% and 20% respectively. LFK index was 0.88, 0.30 and 1.62 for OP, LP and RALP respectively, suggesting no or minor publication bias. The overall success rates of OP, LP and RALP re-do pyeloplasty were 93.1% (95% CI 86–98), 92.1% (95% CI 83–96) and 89.4% (95% CI 83–96) respectively (summary table). The success rate between the techniques was not significantly different, with p values (x2) of 1 (OP vs LP), 0.5 (OP vs RALP) and 0.6 (LP vs RALP). Overall, redo RALP took significantly longer time than redo LP (p < 0.001, Fisher's). Overall, RALP had significantly shorter hospital stay than LP (p < 0.001) and LP had significantly shorter hospital stay than OP (p < 0.001). The complication rate was 9% in OP and LP and 16% in RALP, the difference being not statistically significant (p value 1, 0.26 and 0.27 for OP vs LP, OP vs RALP and LP vs RALP respectively, x2). In conclusion MIS techniques (LP and RALP) seem to be good alternatives to OP for redo pyeloplasty in children, with comparable success and complications. Redo RALP had longer duration of surgery but shorter hospital stay than redo LP. With comparable success & complication rate between RALP and LP, this MA could not favor one over the other for redo pyeloplasty. [ABSTRACT FROM AUTHOR]

Objective: To describe patient characteristics and post-operative outcomes, including early and late mortality, defined by death within 30 days and after 30 days post-surgery, respectively, as well as 20-year survival after isolated reoperative tricuspid surgery. Methods: We retrospectively analyzed 169 patients who underwent isolated reoperative tricuspid valve surgery at our institution (between 1997 and 2000) and describe post-surgical outcomes including intraoperative, early and late mortality. All patients included completed 21 years of follow-up. Results: The majority of our patients were females 147 (87%) with the mean age of 45.9 ± 12.9 years. The mean body mass index (BMI, kg/m²) was 27.4 ± 6.0. Previous cardiac surgeries included tricuspid valve surgeries in 169 (100%) patients, with bioprosthetic valves, mechanical valves, annual rings and tricuspid repair surgeries utilized in 37 (21.9%), 21 (12.4%), 38 (22.4%) and 73 (43.2%) patients, respectively. The indication for previous tricuspid surgery was rheumatic heart disease in 154 (91.5%) patients. The most common cause of reoperative valvular surgery was tricuspid regurgitation (TR) in 139 (82.2%), with 66% of patients having severe TR. Other reasons for reoperative surgery included tricuspid stenosis 22 (13%) and dehiscence 8 (4.7%). For the redo surgery, 125 (74%) patients underwent Tricuspid Valve Replacement (TVR), 90 (53%) of whom received bioprosthetic valves while 35 (21%) received mechanical valves. Forty-four patients (26%) underwent Tricuspid Valve Repair. Mortality within 30 days of surgery was 11.3% (20 patients) and 11.4% after 30 days, with 20 years survival being about 80%. Conclusions: Based on our experience, reoperation for failed isolated tricuspid valve replacement or repair was associated with reasonable mortality and good survival rate over long period of time. [ABSTRACT FROM AUTHOR]

The aim of the present study was to describe a bicaval endovascular occlusion technique in minimally invasive tricuspid valve (TV) surgery in patients with previous cardiac surgery. Case series. Single tertiary university center. The study comprised ten patients. Endovascular occlusion of vena cavae for minimally invasive TV redo surgery. Between 2008 and 2017, ten patients with previous cardiac surgery underwent TV minimally invasive surgery (repair or replacement; isolated or with concomitant procedures) using the Coda balloon catheter (Cook Medical, Bloomington, IN) to occlude both vena cavae. Data were collected retrospectively from electronic medical records. Superior and inferior vena cava occlusion with Coda balloon catheters was successful with no complications. The drainage of the vena cavae was optimal with excellent surgical exposure. Cardiopulmonary bypass time was 131 ± 119 minutes, with 30% of patients undergoing aortic clamping (two with a Chitwood clamp, one with an endoaortic balloon). Intensive care unit length of stay was 3.9 ± 2.7 days, and the in-hospital mortality rate was 30%. Bicaval endovascular occlusion of vena cavae is a feasible and effective technique in patients with previous cardiac surgery who are undergoing a minimally invasive TV procedure. The high mortality rate is associated with the inherent risk of a redo surgery involving the TV. [ABSTRACT FROM AUTHOR]

Highlights • A long biliopancreatic limb RYGB as revisional procedure after a failing LAGB improves short- and long-term %TBWL compared to a standard RYGB. • A long biliopancreatic limb RYGB results in good remission of type 2 diabetes. • A long biliopancreatic limb RYGB is not technically more difficult to perform compared to a standard RYGB. • Lengthening the biliopancreatic limb does not result in an increase in vitamin and mineral deficiencies. Abstract Background For a number of years the laparoscopic adjustable gastric band has been one of the leading bariatric procedures with good short-term outcomes. However, inadequate weight loss, weight regain, and other band-related complications in the long term led to an increase in revisional Roux-en-Y gastric bypass (RYGB) procedures. Lengthening the biliopancreatic limb, a relatively simple and safe adjustment of the standard technique, could improve the results of the revisional procedure. Objectives The aim of this randomized controlled trial was to evaluate the effect of a long biliopancreatic limb RYGB (LBP-GB) and standard RYGB (S-GB) as revisional procedure after laparoscopic adjustable gastric band. Setting General hospital specialized in bariatric surgery Methods One hundred forty-six patients were randomized in 2 groups; 73 patients underwent an S-GB (alimentary/biliopancreatic limb 150/75 cm), and 73 patients underwent LBP-GB (alimentary/biliopancreatic limb 75/150). Weight loss, remission of co-morbidities, quality of life, and complications were assessed during a period of 4 years. Results Baseline characteristics between the groups were comparable. At 48 months the follow-up rate was 95%. Mean total weight loss after 24 months was 27% for LBP-GB versus 22% S-GB (P =.015); mean total weight loss after 48 months was 23% and 18%, respectively (P =.036). No significant differences in other parameters were found between the groups. Conclusions A LBP-GB as revisional procedure after a failing laparoscopic adjustable gastric band improves short- and long-term total weight loss compared with an S-GB. Together with future modifications this technically simple adjustment of the RYGB could significantly improve disappointing results after revisional surgery. [ABSTRACT FROM AUTHOR]

Objective Transcatheter mitral valve-in-valve/valve-in-ring procedures (TM-VIVoR) are increasing. The authors aimed to identify independent predictors for hospital mortality in redo mitral valve surgery as possible future selection criteria for TM-VIVoR. Design Retrospective multicenter registry. Setting Tertiary university and community hospitals. Participants Two-hundred and sixty patients (out of 920 enrolled) who are potentially candidates for TM-VIVoR undergoing redo-surgery. Interventions Redo mitral surgery. Measurements and Main Results Regression analyzes and receiver operating characteristic (ROC) curves identified independent predictors of death. Patients potentially candidates for TM-VIVoR reported significant hospital mortality (9.2%; EuroSCORE II: 13.2 ± 13.1, Society of Thoracic Surgeons [STS] score: 6.2 ± 3.1) and major morbidity (3.8% acute myocardial infarction, 5% stroke, 16.9% perioperative respiratory failure, 16.5% acute renal insufficiency, 25% massive transfusions). EuroSCORE II (odds ration [OR] 1.06; confidence interval [CI] 1.01-1.10; p = 0.005), STS score (OR 1.58; CI 1.27-1.97; p = 0.001), age at surgery (OR 1.05; CI 1.00-1.15; p = 0.05), preoperative dialysis (OR 2.5; CI 1.8-12.6; p = 0.042), left ventricular ejection fraction (LVEF) <30% (OR 4.8; CI 1.12-37.1; p = 0.021), severe pulmonary hypertension (OR 7.5; CI 1.9-29.4; p = 0.003), and previous coronary artery bypass grafting (CABG) (OR 11.8; CI 1.7-36.9; p = 0.002) were independent predictors of hospital mortality. ROC analyses reported good prediction for EuroSCORE II (AUC: 0.76; cut-off value: >13.1; 70.8% sensitivity and 68.2% specificity) and better prediction for STS score (AUC: 0.81; cut-off value: 7.4; 75.0% sensitivity and 66.2% specificity). Quintiles stratification identified EuroSCORE II ≥18.7 (5th quintile, observed mortality: 19.3%) and STS score >9.1 as strong predictors of death within each risk-categorization (OR 5.9 and 12.1, respectively). Conclusions High EuroSCORE II and STS scores, advanced age at surgery, LVEF <30%, previous CABG, severe pulmonary hypertension or preoperative dialysis might represent in the future preferred indications for TM-VIVoR in the redo-mitral surgery scenario. [ABSTRACT FROM AUTHOR]

Objectives To report our initial experience in redo hypospadias repair with a lingual mucosal graft (LMG) using a two-stage Bracka technique. Patients and methods This study was prospectively conducted and included 26 patients with hypospadias with failed previous repairs. All the patients had a LMG using a two-stage Bracka technique. In the first stage, the harvested LMG, from the ventro-lateral surface of the tongue, was implanted in a well-prepared vascularised bed in the ventral aspect of the penis. After 6 months, tubularisation of the well-taken graft was completed. Tunica vaginalis or a dartos flap was used as second-layer coverage of the neourethra. Success was defined as acceptable aesthetic and functional outcomes without any additional surgical interventions. Results The mean (SD) patient age was 5.15 (1.6) years. The mean (SD) LMG length was 3.82 (0.9) cm and the width was 1.5 (0.5) cm. The mean (SD) number of previous repairs was 2.76 (1.1). The mean (SD) follow-up was 12 (2) months. Donor-site complications included: pain in all patients, with a pain score of >3 on the visual analogue pain scale (0–10) in 10 (38%); and speech problems in 19 (73%). First-stage complications were graft loss ( n = 2) and contracture ( n = 1). The second stage was completed in 23 patients resulting in the following significant complications: meatal stenosis plus fistula ( n = 2), breakdown ( n = 1). Successful hypospadias repair was achieved in 77% (20/26) of the patients. Conclusion Lingual mucosa is a reliable and versatile graft material in the armamentarium of two-stage Bracka hypospadias repair with the merits of easy harvesting and minor donor-site complications. [ABSTRACT FROM AUTHOR]

This study aims to investigate the trends, outcomes, and risk factors for mortality after redo orthotopic heart transplantation. The United Network for Organ Sharing registry was used to identify adult orthotopic heart transplantation recipients from 2000 to 2020 and stratify into primary and redo cohorts. Five-year post-transplant survival was compared between 2 propensity-matched cohorts. Multivariable modeling was performed to identify risk-adjusted predictors of redo post-transplant mortality, both conditional and nonconditional on shorter-term survival. A total of 40,711 recipients were analyzed, 39,657 (97.4%) primary and 1054 (2.6%) redo. Redo recipients had a lower median age and were more frequently bridged with intravenous inotropes, intra-aortic balloon pump, or extracorporeal membrane oxygenation (all P <. 05). One- and 5-year survivals were lower after redo orthotopic heart transplantation (90.0% vs 83.4% and 77.6% vs 68.6%, respectively) and remained lower after comparing 2 propensity-matched cohorts. Multivariable modeling found factors such as increasing donor age and graft ischemic times, along with pretransplant mechanical ventilation and blood transfusion, to negatively affect 90-day survival. Contingent on 1-year survival, donor factors such as hypertension (hazard ratio, 1.51; 95% confidence interval, 1.15-2.00, P =.004) and left ventricular ejection fraction less than 50% (hazard ratio, 2.22, 95% confidence interval, 1.16-4.24, P =.016) negatively affected survival at 5 years. Although infrequently performed, redo orthotopic heart transplantation remains associated with worse post-transplant outcomes compared with primary orthotopic heart transplantation. Although several high-risk features were identified to affect post-retransplant outcomes in the acute perioperative period, donor characteristics such as hypertension and decreased ejection fraction continue to have lasting negative impacts in the longer term. Redo cardiac transplantation comprised 2.6% of all isolated heart transplants performed between 2000 and 2020, of which chronic rejection/chronic allograft vasculopathy was the most common indication (68.0%). Five-year survival after redo transplantation remains lower than after primary heart transplant, even in propensity score–matched cohorts. Although certain factors such as older donor age and longer graft cold ischemic times affect short-term survival, donor factors such as history of hypertension and reduced ejection fraction affect 5-year mortality. Shaded survival bands represent the 95% CI. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population. Methods The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016. Results 56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common. Conclusion The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed. [ABSTRACT FROM AUTHOR]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: The purpose of this study was to report our large, single-center experience of transabdominal ileal pouch-anal anastomoses (IPAA) redo surgery for a failed initial IPAA. Background: IPAA fail from 3% to 15% of the times, mainly due to technical or inflammatory conditions. There is limited information about the surgical, functional, and quality-of-life (QOL) outcomes of redo surgery for failed IPAA, especially in large series of patients. Methods: Patients undergoing transabdominal redo surgery for failed IPAA between 1983 and 2014 were evaluated. Primary endpoints were morbidity of the surgery, the proportion of patients with a functioning pouch, frequency of defecation and incidence of incontinence, and the patients' perception of QOL. Results: There were 502 (43% males) patients with a median age of 38 years and median body mass index 24 kg/m2 at the time of revision surgery. A new pouch was created in 41% of patients whereas 59% had their original pouch revised and retained. Postoperative mortality was 0% and morbidity was 53%. The short-term anastomotic leak rate was 8%. At a median follow-up of 7 years after redo surgery, 101 (n=20%) patients had redo IPAA failure. Pelvic sepsis developing after redo ileal pouch surgery was the primary indicator of pouch failure (hazard ratio, 3.691; 95% confidence interval, 2.411-5.699; P<0.0001). Overall functional outcomes and QOL scores were acceptable. Conclusions: Patients with a failed ileoanal pouch may be offered redo pouch surgery with a high likelihood of success in terms of function and QOL. [ABSTRACT FROM AUTHOR]

Background: revisional bariatric surgery is gaining increasing interest as long term follow-up studies demonstrate an elevated failure rate of primary surgery due to insufficient weight loss, weight regain or complications. This particularly concerns restrictive bariatric surgery which has been widely adopted from the '80s till present through different procedures, notably vertical banded gastroplasty, laparoscopic adjusted gastric banding and sleeve gastrectomy. The aim of this study is to define which revisional bariatric procedure performs the best after failure of primary restrictive surgery.Methods: a systematic review and network meta-analysis of 39 studies was conducted following the PRISMA guidelines and the Cochrane protocol.Results: biliopancreatic diversion with duodenal switch guarantees the best results in terms of weight loss (1 and 3-years %TWL MD: 12.38 and 28.42) followed by single-anastomosis duodenoileal bypass (9.24 and 19.13), one-anastomosis gastric bypass (7.16 and 13.1), and Roux-en-Y gastric bypass (4.68 and 7.3) compared to re-sleeve gastrectomy. Duodenal switch and Roux-en-Y gastric bypass are associated to an increased risk of late major morbidity (OR: 3.07 and 2.11 respectively) compared to re-sleeve gastrectomy while no significant difference was highlighted for the other procedures. Re-sleeve gastrectomy is the revisional intervention most frequently burdened by weight recidivism; compared to it, patients undergoing single-anastomosis duodenoileal bypass have the lowest risk of weight regain (OR: 0.07).Conclusion: considering the analyzed outcomes altogether, single-anastomosis duodenoileal bypass and one-anastomosis gastric bypass are the most performing revisional procedures after failure of restrictive surgery due to satisfying short and mid-term weight loss and low early and late morbidity. Moreover, single-anastomosis duodenoileal bypass has low risk of weight recidivism. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: This article is aimed at describing a series of 70 patients who underwent a redo pull-through in the period between January 1991 and January 2007 and to compare them with a series of consecutive patients with Hirschsprung disease who underwent a single pull-through. Methods: The notes were reviewed, and a comprehensive interview based on a disease-specific questionnaire for continence and quality of life was submitted to all eligible patients. We used a number of consecutive patients who underwent a single pull-through for Hirschsprung disease as control group. Results: Seventy patients were included. Residual aganglionosis in pulled-through bowel or retained aganglionic rectum represented the indications to reoperation in most cases. Intestinal obstruction represented the leading symptom in more than 60% of patients. We adopted either the endorectal pull-through, the Duhamel, or the Swenson procedure. Thirty-six patients were assessed for long-term outcome. One third experienced complications. Long-term continence was satisfactory in 70%. Enterocolitis, soiling, and perineal excoriations were complained by 30%. Excellent to good perspectives were described by 94%, and excellent to good cosmetic results by 22%. The only significant difference with control group (109 patients) involved cosmetic appearance, whereas soiling, although more frequent, could not be considered significantly increased. Conclusions: Patients who experience failure of a pull-through must go through multiple procedures to achieve definitive results. Although overall outcome does not significantly differ from that of a single effective pull-through, great efforts should be made to minimize complications and avoid the need for a redo, which requires experienced surgeons and highly committed families for a longer course of the disease. [Copyright &y& Elsevier]

Introduction Pulmonary vein (PV) isolation has become a cornerstone therapy for symptomatic paroxysmal AF refractory to anti-arrhythmic drugs. Nowadays, the most common energies used to achieve PV isolation are cryoenergy and radiofrequency (RF). However, approximately one third of the patients have recurrences, mainly due to PV reconnections. Little is known about the characteristics of the redo procedure, depending on the choice of the initial energy. Methods Patients referred to our center for a RF redo ablation procedure of symptomatic paroxysmal AF (PxAF) between 2010 and 2014 were retrospectively enrolled. Demographic data and characteristics of the initial ablation, i.e. cryoenergy or RF ablations, were collected. Number and location of PV gaps, and redo characteristics were reviewed. Results 74 patients scheduled for a redo ablation of AF were included, 38 and 36 using RF or cryoablation for the first procedure, respectively. For the initial ablation, procedural and fluoroscopy times were significantly shorter when using cryoenergy (147.8±52.6 vs. 226.6±64.3 min, p<0.001, and 37.0±17.7 vs. 50.8±22.7 min, p=0.005, respectively). Overall, an identical number of gaps were found during redo procedures of cryo and RF ablations. However, a significantly higher number of gaps were located in the right superior PV (RSPV) for patient first ablated with RF (0.9±1.0 vs. 0.5±0.9, p=0.009). The location of gaps was different, predominantly found in the anterior and superior parts of the left superior PV (LSPV), the anterior and inferior part of the left inferior PV (LIPV), the superior part of the right superior PV (RSPV), and in the postero-inferior part of the right inferior PV (RIPV) when using RF as the initial energy. For patient first ablated with cryoenergy, gaps were predominantly found in the anterior part of the left PV, evenly distributed in the RSPV, and in the postero-inferior part of the RIPV. Although not significant, redo procedures of cryoablations were slightly shorter and needed less RF duration times to achieve PV isolation (160.0±55.7 vs. 175.7±59.1 min, p=NS, and 954.1±796.7 vs. 1476.7±1269.6, p=NS). Conclusion During redo procedures, gaps location pattern is different for patients first ablated with cryo or RF energy, and RSPV reconnections occur more frequently after RF ablation, probably due to poor contact in this region. Procedural characteristics of the redo ablation are similar. Abstract 0029 – Figure: Localization of gaps, during the redo procedure [ABSTRACT FROM AUTHOR]

Summary: The aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47patients. Patients and methods: Between 1995 and 2011, 595patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47patients required a re-operative fundoplication (RFP). In 11patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2years were matched to patients who had been operated only once to assess satisfaction and quality of life. Results: Short term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2years (mean: 4,5years) (Group RFP) were compared to a matched group of 29patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6days, p <0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p =NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs 84, p <0.05). Conclusion: Re-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life. [Copyright &y& Elsevier]

Copyright of IRBM is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)