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Objective: Management of patients after failed epilepsy surgery is still challenging. Advanced diagnostic and intraoperative tools including magneto-encephalography (MEG) as well as neuronavigation and intraoperative magnetic resonance imaging (iopMRI) may contribute to a better postoperative seizure outcome in this patient group. Methods: We retrospectively analyzed consecutive patients after reoperation of failed epilepsy surgery for medically refractory epilepsy at the University of Erlangen between 1988 and 2017. Inclusion criteria for patients were available MEG, neuronavigation and iopMRI data. The Engel scale was used to categorize seizure outcome. Results: We report on 27 consecutive patients (13 female/14 male mean age at first surgery 29.4 years) who had operative revision of the first resection after failed epilepsy surgery. An improved seizure outcome postoperatively was observed in 78% of patients (p < 0.001) with 55% seizure free (Engel I) patients after a mean follow-up time of 4.9 years. In detail, 80% of lesional cases were seizure free compared to 59% of MRI negative patients. Localizing MEG spike activity in the vicinity of the first resection cavity was present in 12 of 27 patients (44%) corresponding to 83% (10/12) of MEG localizing spike patients having advanced seizure outcome after operative revision. Conclusion: Re-operation after failed surgery in refractory epilepsy may lead to a better seizure outcome in the majority of patients. Preoperative MEG may support the decision for surgery and may facilitate targeting epileptogenic tissue for re-resection by employing navigation and iopMR imaging.

We investigated if patient-reported outcomes (PROMs) one year after total hip replacement (THR) can predict the risk of re-operation using data from the Swedish Hip Arthroplasty Register. A total of 75,899 patients with THR due to osteoarthritis operated in 2002–2014 were included. We used Kaplan-Meier and Cox regression to investigate the relationship between one-year post-operative PROMs and risk of re-operation (all types of further hip surgery). The predictive power of the model and post-operative PROMs were evaluated by concordance index (C). Kaplan-Meier estimates for not being re-operated at eight years was 95.5% (95%CI; 95.3–95.8). Cox regression analyses showed that all PROMs, except for EQ-VAS, were associated with re-operation. The full model had a concordance index of 0.68. Satisfaction (C = 0.65) and pain (C = 0.65) in isolation had the highest predictive power. Worse PROMs predicted higher risk of re-operation. Therefore, we believe PROMs may be helpful in identifying patients at risk for re-operation and timely address their problems.

Studies that evaluate the predictors and causes of unplanned re-operation in outpatient plastic surgery. This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all plastic surgery outpatient cases performed in 2011. Multiple logistic regression analysis was utilised to identify independent risk factors and causes of unplanned reoperations. Of the 6749 outpatient plastic surgery cases identified, there were 125 (1.9%) unplanned re-operations (UR). Regression analysis demonstrated that body mass index (BMI, OR = 1.041, 95% CI = 1.019-1.065), preoperative open wound/wound infection (OR = 3.498, 95% CI = 1.593-7.678), American Society of Anesthesiologists (ASA) class 3 (OR = 2.235, 95% CI = 1.048-4.765), and total work relative value units (RVU, OR = 1.014, 95% CI = 1.005-1.024) were significantly predictive of UR. Additionally, the presence of any complication was significantly associated with UR (OR = 15.065, 95% CI = 5.705-39.781). In an era of outcomes-driven medicine, unplanned re-operation is a critical quality indicator for ambulatory plastic surgery facilities. The identified risk factors will aid in surgical planning and risk adjustment.

While an increasing amount of arthroplasty articles report comorbidity measures, none have been validated for outcomes. In this study, we compared commonly used International Classification of Diseases-based comorbidity measures with re-operation rates after total hip replacement (THR). Scores used included the Charlson, the Royal College of Surgeons Charlson, and the Elixhauser comorbidity score. We identified a nationwide cohort of 134 423 THRs from the Swedish Hip Arthroplasty Register. Re-operations were registered post-operatively for up to 12 years. The hazard ratio was estimated by Cox’s proportional hazards regression, and we used C-statistics to assess each measure’s ability to predict re-operation. Confounding variables were age, gender, type of implant fixation, hospital category, hospital implant volume and year of surgery. In the first two years only the Elixhauser score showed any significant relationship with increased risk of re-operation, with increased scores for both one to two and three or more comorbidities. However, the predictive C-statistic in this period for the Elixhauser score was poor (0.52). None of the measures proved to be of any value between two and 12 years. They might be of value in large cohort or registry studies, but not for the individual patient. Cite this article: Bone Joint J 2013;95-B:1184–91.

Summary Objective To determine and compare failure, re-operation, and complication rates of all generations and techniques of autologous chondrocyte implantation (ACI). Methods A systematic review of multiple medical databases was performed according to PRISMA guidelines. Levels I–IV evidence were included. Generations of ACI and complications after ACI were explicitly defined. All subject and defect demographic data were analyzed. Modified Coleman Methodology Scores (MCMSs) were calculated for all studies. Results 82 studies were identified for inclusion (5276 subjects were analyzed; 6080 defects). Ninety percent of the studies in this review were rated poor according to the MCMS. There were 305 failures overall (5.8% subjects; mean time to failure 22 months). Failure rate was highest with periosteal ACI (PACI). Failure rates after PACI, collagen-membrane cover ACI (CACI), second generation, and all-arthroscopic, second-generation ACI were 7.7%, 1.5%, 3.3%, and 0.83%, respectively. The failure rate of arthrotomy-based ACI was 6.1% vs 0.83% for all-arthroscopic ACI. Overall rate of re-operation was 33%. Re-operation rate after PACI, CACI, and second-generation ACI was 36%, 40%, and 18%, respectively. However, upon exclusion of planned second-look arthroscopy, re-operation rate was highest after PACI. Unplanned re-operation rates after PACI, CACI, second-generation, and all-arthroscopic second-generation ACI were 27%, 5%, 5%, and 1.4%, respectively. Low numbers of patients undergoing third-generation ACI precluded comparative analysis of this group. Conclusions Failure rate after all ACI generations is low (1.5–7.7%). Failure rate is highest with PACI, and lower with CACI and second-generation techniques. One out of three ACI patients underwent a re-operation. Unplanned re-operations are seen most often following PACI. Hypertrophy and delamination is most commonly seen after PACI. Arthrofibrosis is most commonly seen after arthrotomy-based ACI. Use of a collagen-membrane cover, second-generation techniques, and all-arthroscopic, second-generation approaches have reduced the failure, complication, and re-operation rate after ACI.

Strabismus surgery with adjustable sutures of absorbable material was performed in 19 patients, aged 8-69 years, who had paralytic strabismus and/or were re-operated. The ocular alignment was assessed at 1 week and 3-12 months post-operatively. In 12 of the patients eye position was stable during that period. Eleven of them had good or moderate binocular vision. However, eye position changed over the follow-up period in about half of the patients with poor binocular vision. No evidence was found for any muscle repositioning by mechanical stress during suture absorption.

BACKGROUND Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. METHODS From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 +/- 11 years, mean original weight 151.3 +/- 44.3 kg, mean BMI 58.4 +/- 16.9 kg/m2 and mean excess body weight (EBW) 94.4 +/- 43.5 kg. Mean height was 161 +/- 7.7 cm, and 15 patients were female (88.2%). The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). RESULTS Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP, 1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. CONCLUSION Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.

We asked whether patients under long-term warfarin and managed with current guidelines regarding bridging therapy have a higher complications rate within ninety days following total knee arthroplasty. We retrospectively identified 38 patients under long-term warfarin. They were match-paired with 76 control patients. Our results showed a significant increased rate of complications (42.1% vs. 6.9%, P < 0.001) and re-operation (21.1% vs. 5.2%, P < 0.001) in the warfarin group. The difference was related to the number of hematomas requiring surgical evacuation. The warfarin group had a significantly higher rate of blood loss, blood transfusion, and length of hospital stay. Our data suggest that current guidelines for preoperative warfarin management are associated with a high rate of bleeding complications and reoperations following TKA.

To define the risk factors of complications which are followed by re-operations in patients with cardiac and pericardial wounds and to prevent these complications.Retrospective and prospective analysis of 1072 victims with cardiac and pericardial injuries for 35 years was performed. Overall mortality was 17.2%. 98 patients died during surgery. Postoperative bleeding was observed in 38 (3.9%) cases.In 28 cases re-operations were performed for bleeding-related complications. Indications for re-thoracotomy were one-time drainage from pleural cavity over 500 ml or bleeding rate over 100 ml per hour for 4 hours. Prevention of postoperative bleeding in case of cardiac and pericardial wounds was developed on basis of analysis of these observations.Risk factors of complications requiring re-operation are cardiomyopathy of different etiology, technical and tactical errors during primary intervention and hypocoagulation with massive blood loss. Prevention of these complications includes careful heart wound closure, comprehensive intraoperative control, correction of hemostatic system.Цель исследования - выявление факторов, способствующих развитию осложнений, требующих выполнения повторных оперативных вмешательств при ранениях сердца и перикарда, определение мер профилактики этих осложнений. Материал и методы. Проведен ретроспективный и проспективный анализ 1072 наблюдений ранений сердца и перикарда за 35 лет. Общая летальность составила 17,2%. В момент выполнения оперативного вмешательства умерли 98 раненых. Послеоперационные кровотечения наблюдали у 38 (3,9%) пострадавших, перенесших операцию. Результаты. Выполнения повторных хирургических вмешательств в 28 наблюдениях потребовали осложнения, связанные с кровотечением. Показанием к реторакотомии считали одномоментное поступление по дренажам плевральной полости крови в объеме 500 мл и более или кровотечение с темпом более 100 мл в час в течение 4 ч. На основании анализа этих наблюдений сформулированы меры профилактики послеоперационных кровотечений при ранениях сердца и перикарда. Вывод. Факторами, способствующими развитию осложнений, которые требуют выполнения повторных оперативных вмешательств при ранениях сердца и перикарда, являются кардиомиопатия различной этиологии, технические и тактические ошибки в ходе первичного вмешательства, а также гипокоагуляция при массивной кровопотере. Профилактика этих осложнений заключается в тщательном соблюдении техники ушивания ран сердца, полноценной интраоперационной ревизии, коррекции системы гемостаза.

Aims: Cardiac surgery patients are prone to bleeding postoperatively owing to the extensive sternotomy wound, multiple vessel and heart sutures, and disorders of hemostasis. In this study we retrospectively analyzed the outcomes for all patients in our department who were re-operated for bleeding, over a 5 year period. Methods: A total of 4297 patients underwent heart surgery between February 2002 and January 2007, of which 98 (2.3 %) were emergency reoperations for bleeding. We analyzed the process of indication for repeat surgery, possible source of bleeding, and postoperative complications. Results: Most (85.7 %) of the reoperated patients had undergone their first operation as an elective cardiac procedure. The mean blood loss before the reoperation was 1557 ml. The studied group was characterized by increased mortality (11.2 %), longer ventilation period (35.1 hours) and ICU (4.5 days) and hospital (13.3 days) stays. The postoperative outcomes did not differ significantly between patients with TEG-detected coagulation disorder and the rest of the patients, or between patients treated with antilysin and those who did not receive antifibrinolytics. Conclusions: It is vital for the indication process leading to reoperation of the bleeding patient to be as short as possible so as to minimize the delay to repeat surgery. Echocardiography including ultrasound of both pleural spaces, and TEG could shorten that time delay, and should always be included when evaluating patients. Platelets should be administered more often, with the use of antifibrinolytics reserved for cases with confirmed fibrinolysis.

Roux-en-Y gastric bypass (RYGBP) has been demonstrated to be an effective treatment for weight loss in the morbidly obese. Numerous variations of the RYGBP have been performed, including placing a ring proximal to the gastric outlet. This ring in RYGBP is intended to decrease pouch dilation and limit weight regain. We reviewed our experience in laparoscopic re-operation after open banded RYGBP. All charts of patients who underwent laparoscopic revisional bariatric surgery were reviewed. Patients who had laparoscopic removal of the band following the open banded RYGBP were reviewed in this study. There were 4 patients who had laparoscopic removal of the band. The indication in all patients was dysphagia and emesis. The ring removed was a silicone band (1) and a large braided non-absorbable suture (3). After the laparoscopic reoperation, there was immediate relief. There has been an average of 5.8 kg weight regain at average followup of 30 months. This complication after open banded RYGBP may require operative intervention. Laparoscopic removal of a band is feasible and safe.

To examine the efficacy of amniotic membrane transplantation (AMT) and/or botulinum toxin type A-induced ptosis (Dysport) in the treatment of corneal ulcerations of different entities.Retrospective evaluation of 137 cases of corneal ulcers which have been treated with AMT, botulinum toxin type A and perforating keratoplasty (pKP). Regarding corneal ulcerations the patients were divided into three groups: group A, patients initially having received an AMT (92 eyes eventually followed by AMT or pKP as a second intervention); group B, patients initially having received an AMT (32 eyes followed by botulinum toxin type A injection in the upper lid as a second intervention); group C, patients initially treated only by botulinum toxin type A injection (13 eyes followed occasionally by AMT or pKP or additional botulinum toxin type A injection). Additionally, we analysed the complete epithelialisation rate of the ocular surface in respect to different ocular and systemic diseases and compared the frequency of re-operations in each group.The overall follow-up was 14.2 (+/-14.7 months; range from 1 to 60 months). The total frequency of re-operations was 45.3% (overall time until complete epithelialisation 12.7 (+/-6.1) days). If the patient was initially treated with an AMT (group A), the re-operation rate was 44.6%. Treating affected eyes in this group with a subsequent amniotic membrane resulted in a reduction of re-operation rate to 30.4%. In cases with induced ptosis by injecting botulinum toxin type A in the M. levator palpebrae (group B), the re-operation frequency could be reduced to 34.4% with similar times of epithelialisation [group A: 12.0 (+/-6.5) days and group B: 11.7 (+/-5.5) days]. In group C, with botulinum toxin type A alone initially, the re-operation rate of 69.2% was the highest one compared with groups A and B; this rate could be drastically reduced by a following AMT to 23.1%. Surprisingly, in the few successful cases with botulinum toxin type A alone a quite low epithelialisation time of 6.5 (+/-1.3) days was achieved, but turned out to be similar after additional interventions if compared with the other groups (botulinum toxin type A + AMT: 15.7 (+/-4.9) day).AMT alone and combined with botulinum toxin type A-induced ptosis is an effective surgical approach for managing severe corneal ulcerations by promoting wound healing and stabilizing ocular surface homeostasis.

The widespread use of meshes for the repair of incisional hernia is currently followed by an increasing number of re-operations. The incidence of incisional hernia recurrence after mesh repair varies between 3 and 32%. The problem of mesh failure and options for another surgical intervention seem rather unattended. We present our experience of 77 re-operations after previous mesh repair that were performed between 1995 and 2004 out of a total of 1,070 operations for incisional hernia. The retrospective analysis focused on recurrence in relation to location, material of the previous mesh repair and the surgical procedure to resolve the problem. The locations of the preceding meshes were epifascial as onlays (n=23), retromuscular as sublays (n=46), within the defect as inlays (n=6) or intraperitoneally (n=2). The direction of the incision was vertical medial (n=41) or horizontal crossing the linea semilunaris (n=36). Recurrences after median incisional hernia mesh repair mainly occurred at the cranial border of the mesh subxiphoidal. Except for two patients, all recurrences manifested at the margin of the enclosed mesh. Re-operation after previous mesh repair is a surgical challenge. The type of revision procedure has to consider the position and material of the previous mesh. In our clinic recurrences, heavyweight polypropylene meshes were mostly treated with mesh exchange and lightweight polypropylene meshes could be treated by extension with a second mesh. In contrast to suture techniques, deficient mesh repairs are more evidently related to technical problems.

The Austin Moore prosthesis is commonly used for displaced femoral neck fractures. In this study the rate of re-operation following Austin Moore hemiarthroplasty was studied. Ten out of 88 cases (11.36%) were re-operated on within the first year following the original operations. The indications for re-operation were infection (4.5%), dislocation (3.4%) and loose prosthesis (3.4%). The rate of infection found in this study was higher than other published series and could be attributed to the lack of laminar flow ventilation system and the use of cotton drapes and surgical gowns while performing these operations. We recommend that Austin Moore hemiarthroplasty should be carried out in theatres equipped with a laminar flow ventilation system and to use waterproof gowns and drapes to limit the number of deep infections and therefore lower the re-operation rate.

Over a period of 5 years, 55 re-operations with internal fixation were performed on 51 patients. The re-operations constituted 9.2 per cent of all operations employing internal fixation for subcapital fractures of the femur during that period. The indications for re-nailing were penetration of the nail through the femoral head, or slipping of the nail, with or without dislocation of the fracture. Only 26 per cent of the re-nailed fractures healed. Seventy-three per cent showed avascular necrosis and 61 per cent non-union.