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We report a novel use of transcatheter aortic valve replacement (TAVR) for valve-in-valve tricuspid valve replacement. A man in his 50s with prohibitive risks for surgical intervention underwent this procedure to improve severe, symptomatic tricuspid stenosis. Though current literature is limited to case reports, the Valve-in-Valve International Database (VIVID) reports similar mortality rates between surgical and transcutaneous replacement. As a novel, off-label procedure, there is limited operator experience. Nonetheless, in non-operative or high-risk patients, similar outcomes are noted in between transcatheter tricuspid valve replacement and surgical replacement. This registry sets the framework for further studies with the possibility of observing outcomes as operator experience increases, while highlighting the feasibility of the procedure.

Testicular replantation represents a unique circumstance. There are very few reports documenting their experience with testicle replantation and to the best of the authors' knowledge, this is the first case that has been reported in the peer-reviewed literature following a wrong site surgery. Therefore, we detail our technique and outcome when faced with such a rare event. In addition we review the literature, in order to compare and report the experience of others. This case highlights the value of applied microsurgical knowledge and the importance of cross-disciplinary efforts to improve patient outcomes.

OBJECTIVES The goal of this study was to evaluate the surgical outcomes of a valve-sparing root replacement using the reimplantation technique for annuloaortic ectasia in patients with Marfan syndrome (MFS) and in those with Loeys-Dietz syndrome (LDS). METHODS We reviewed 103 patients with MSF with mutations in the fibrillin-1 gene and 28 patients with LDS with mutations in the transforming growth factor-beta receptor and 2, SMAD3 and transforming growth factor beta-2 from 1988 to 2020. RESULTS Forty-four (42.7%) patients with MFS [26 men, 31 (7.6) years] and 10 (35.7%) patients with Loeys-Dietz syndrome (LDS) [7 men, 22 (standard deviation: 8.6) years] who had no aortic dissection and underwent valve-sparing root replacement were included. The preoperative sinus diameter [46 (45–50.5) mm in those with MFS vs 48 (47–50) mm in those with LDS, p = 0.420] and the percentage of aortic insufficiency > grade 2+ [31.8% (10/44) in patients with MFS vs 10.0% (1/10) in those with LDS, p = 0.667] revealed no significant differences between the 2 groups. The cumulative incidences of aortic insufficiency greater than grade 1 (p = 0.588) and aortic valve reoperation (p = 0.310) were comparable between the 2 groups. Patients with LDS had a higher tendency towards aortic dissection after the initial operation (p = 0.061) and a significantly higher cumulative incidence of aortic reoperation (p = 0.003) versus those with MFS. CONCLUSIONS Patients with MFS and those with LDS showed similar cumulative incidences of recurrent aortic valve insufficiency and aortic valve reoperation. Those with LDS revealed a higher cumulative incidence of aortic reoperation and a greater tendency towards aortic dissection after the initial operation compared with those with MFS.

Successful replantation relies on proper preservation of traumatically amputated parts. The established protocol for preservation, however, is inconsistently adhered to. The objective of this study is to examine the rate of proper preservation in multiple patient populations.A retrospective review of patients from 2015 to 2019 at a single academic institution was conducted. Patients were included if they suffered a traumatic amputation, the amputated part was present for evaluation by the hand surgery team, and modality of preservation was documented. Additional data including method of patient transport, replantation attempt, and operative outcome were assessed. Patients were stratified based on whether proper preservation was employed and compared using chi-square tests.Ninety-one patients were included, thirty-one (34.1%) of whom had amputated parts which were properly preserved. Patients from referring facilities were more likely to present with properly preserved parts (45.0%) than those presenting from home (25.5%), though this did not meet significance (P = .051). In total, 74 patients arrived via EMS with 35.1% adherence to preservation protocol. Of the 31 patients who had properly preserved parts, 58.1% underwent attempted replant; of the 60 patients who had improperly preserved parts, 23.3% underwent attempted replantation (P = .001).The majority of patients who suffer traumatic amputations do not present with properly preserved amputated parts, limiting potential replantation. With a direct correlation to attempted replantation, proper preservation is a crucial aspect of care and should not be overlooked when seeking to optimize efforts and results.Level IV.

Background Periprosthetic joint infection (PJI) is one of the most challenging complications of total joint arthroplasty (TJI). An early and accurate diagnosis of PJI is associated with better treatment outcomes. However, whether the platelet-related markers and globulin-related markers can be used to assist the diagnosis of PJI remains elusive. Methods A total of 206 patients who underwent revision hip or knee arthroplasty in our institution were divided into two groups: 79 patients in PJI group and 127 patients in aseptic failure group. The levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), platelet-related markers including platelet count (PLT), mean platelet volume (MPV), plateletcrit (PCT) and PLT to MPV ratio (PMR) and globulin-related markers such as globulin (GLB), albumin to globulin ratio (AGR) and PLT to AGR ratio were compared. The diagnostic value was measured using area under the curve (AUC) after constructing receiver operating characteristic (ROC) curves. The potential of each marker for determining the timing of second-staged reimplantation was also evaluated. Results Significantly increased levels of ESR, CRP, PLT, PCT, PMR, GLB and PLT to AGR ratio were identified in PJI group, while decreased levels of MPV and AGR were also found. The diagnostic values of all platelet-related markers and GLB were considered as fair, and good diagnostic values of AGR and PLT to AGR ratio were found, which were comparable to those of ESR and CRP. The levels of GLB and AGR can also be used to predict negative culture result and the timing of second-stage reimplantation. Conclusions Globulin and albumin to globulin ratio were found to have good diagnostic values for PJI, and they can precisely predict the culture results and persistent infection.

Fingertip replantation is technically challenging. Venous congestion is one of the most common causes of replantation failure. Therefore, various venous drainage procedures and salvage techniques have been used in venous congestion. Negative-pressure wound therapy has proven beneficial in limb injuries, yet limited studies of fingertip replantation exist. This study aims to analyze risk factors in fingertip replantation and to evaluate the feasibility and clinical benefits of negative-pressure wound therapy compared with other salvage techniques.From January of 2015 to December of 2019, 27 patients (27 digits) who experienced fingertip amputation over Tamai zone I or II underwent replantation. Salvage negative-pressure wound therapy was applied for venous congestion postoperatively. Replantation data were collected for further analysis.The overall survival rate of digit replantation with salvage negative-pressure wound therapy was 92.6 percent (25 of 27). The blood transfusion rate was 11.1 percent (three of 27). The average hospitalization time was 8.04 ± 1.43 days and the median duration of negative-pressure wound therapy was 6 days (range, 4 to 8 days; interquartile range, 2 days). There is no significant difference between the survival and failure groups for all risk factors evaluated.Negative-pressure wound therapy is a simple and effective salvage option to relieve venous congestion in fingertip replantation with a satisfactory survival rate, low blood transfusion rate, and short inpatient stay.Therapeutic, IV.

Purpose The main objective of our prospective,descriptive,monocentric,longitudinal study is to demonstrate the feasibility of vesicoscopic cross-trigonal ureteral reimplantation under CO2 pneumoves...

Background Descending aortic replacement often involves making large incisions; thus, it results in massive invasions. We report the case of a patient with dilated descending aorta treated using endoscopic-assisted descending aortic replacement with essentially minimal invasions. Case presentation We performed endoscopic-assisted descending aortic replacement with a single incision involving six wounds by trocar puncturing on a 59-year-old man who was diagnosed with dilated descending aorta by stent graft-induced new entry. Subsequently, the patient was discharged on postoperative day 11 without any complications. Conclusions Despite minor incisions, our approach can be indicated to almost the same group of patients in whom the conventional approach can be performed. Our procedure involved a single incision of only 8 cm and six wounds by trocar puncturing. Thus, endoscopic-assisted surgery can be a useful option in descending aortic surgery.

Background Digit replantation under wide-awake local anesthesia is a challenging method, and there are only a few works of literature on this procedure. This article describes the authors' clinical experience in finger replantation under wide-awake local anesthesia compared to general anesthesia. Methods Fifty-one patients who received single finger replantation after initial sharp amputation were included in the study of whom 16 received wide-awake local anesthesia and 35 general anesthesia treatment. The indications for wide-awake local anesthesia were sharp amputation injury, estimated operation time less than 3 hours, and cooperative patients. The wide-awake local anesthesia was performed with 1% or 2% lidocaine infiltrated at the volar midpoint of the metacarpophalangeal joint of the affected digit without sedation medications. Demographic data included surgical outcome, waiting time, operation time, and hospital stay. Results A total of 51 consecutive patients were included in this study. There were significantly shorter waiting times and operation times in the wide-awake local anesthesia group. The other parameters showed no significant differences. The overall success rate was 76.47 percent, with a mean overall operation time of 206 minutes. Conclusions In selected patients, finger replantation can be successfully performed under wide-awake local anesthesia, which has lower anesthesia risk and fewer medical expenses than general anesthesia. The method is feasible for single-digit replantation. Therefore, the finger replantation under wide-awake local anesthesia is a practicable alternative to general anesthesia. Clinical question/level of evidence Therapeutic, III.

Objectives We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery. Methods From 1990 to 2014, 473 patients underwent a Bentall procedure after previous cardiac surgery with a composite valve graft at a single institution: composite valve graft with a mechanical prosthesis (n = 256) or composite valve graft with a bioprosthesis (n = 217). Patients were excluded if their index operation was less than 30 days before the reoperation. The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality: stroke, renal failure, prolonged mechanical ventilation, deep sternal infection, or reoperation during the same admission. Multivariable logistic regression was used to identify risk factors associated with the primary and secondary outcomes of interest. Results Median age was 57 (interquartile range, 44-67) years, and 349 patients (74%) were male. Median time between index surgery and reoperation was 13 (interquartile range, 8-21) years. A total of 178 patients (38%) underwent urgent or emergency intervention, 61 patients (13%) had active endocarditis/abscess, 87 patients (19%) had left ventricular ejection fraction less than 40%, and 262 patients (55%) had undergone more than 1 previous operation. Previous operations (not mutually exclusive) included coronary artery bypass grafting (n = 58, 12%), aortic valve/root replacement (n = 376, 80%) or repair (n = 36, 8%), and other surgical interventions (n = 245, 52%). Ninety-six patients (20%) had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 81 patients, a Ross operation in 8 patients, a valve-sparing root replacement in 4 patients, and an arterial switch in 3 patients. At the time of the reoperative Bentall, both coronary arteries were reimplanted directly in 357 patients (77%), whereas 79 patients (17%) received at least 1 interposition graft. In 26 patients (5%), at least 1 of the native coronary arteries was oversewn and a vein graft bypass was performed. Thirty-day mortality occurred in 37 patients (7.8%), and 152 patients (32%) had major morbidity and operative mortality. On multivariable analysis, risk factors associated with increased 30-day mortality included older age and coronary reimplantation by a technique other than direct anastomosis. Indirect coronary reimplantation was also associated with a higher incidence of major morbidity and operative mortality, as were more than 1 previous cardiac operation and preoperative New York Heart Association functional class III/IV or greater. Conclusions In the largest reported cohort of aortic root replacement after previous cardiac surgery, the reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important factor associated with adverse perioperative events.

Recent evidence suggests that select delayed replantation may not adversely affect digit survival; however, whether surgical timing (overnight or daytime) is associated with digit replantation outcomes is unknown.To assess whether digit survival, complication rate, and duration of surgery are associated with time of replantation.This retrospective case series study included all replantations performed at a single tertiary referral academic center between January 1, 2000, and August 1, 2021. Data were analyzed between October 2, 2021, and January 1, 2022. Four daytime surgery intervals were selected based on literature review. Daytime replantations started within the intervals whereas overnight replantations began outside the intervals. For each case, the procedure difficulty score and the attending surgeon expertise score were calculated. Logistic and linear regressions adjusting for confounders including procedure difficulty score and expertise score were used to assess surgical timing and outcomes. Participants were adults (aged ≥18 years) undergoing digit replantations between January 2000 and August 2021 with at least 1-month follow-up. Replantation was defined as the reattachment of a completely amputated digit that necessitated anastomosis of both artery and vein.Daytime or overnight digit replantation.Viable replanted digit at 1-month follow-up, number of complications, and duration of surgery.A total of 98 patients (mean [SD] age, 39.5 [15.3] years; 136 [93%] men) and 147 digits met inclusion criteria. Overall success rate was 55%. Between 4 pm and 7 am, overnight replantations were associated with 0.4 fewer complications (β, -0.4; 95% CI, -0.8 to -0.1) and 90.7 minutes shorter operative time (β, -90.7; 95% CI, -173.6 to -7.7). A 1-point increase in surgeon expertise score was associated with 1.7 times increased odds of replantation success for all intervals (adjusted odds ratio, 1.7; 95% CI, 1.2 to 2.4; P = .002). There were no differences in digit survival by surgical time.In this case series study of digit replantations, time of operation was not associated with replantation success. Overnight replantation was associated with fewer complications and shorter duration of surgery compared with daytime surgery. Results of this study suggest that overnight replantations may be performed with outcomes comparable to daytime replantations at a tertiary care academic center.

To evaluate the outcomes of ureteral reimplantation (UR) after failure of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) in renal transplant recipients. We conducted a monocentric retrospective study that included all renal transplant recipients with failure of Deflux™ as first-line treatment of VUR from January 2007 to December 2020. Failure of Deflux™ was defined by: VUR on retrograde cystography and at least one acute pyelonephritis of the renal graft. The preferred surgical treatment was native ureteropyelostomy (NPUS) in the recent years. If the native ureter could not be used, ureteroneocystostomy (UNC) was performed. The primary outcome was the clinical efficacy of UR defined as the absence of acute graft pyelonephritis during follow-up. Out of 1565 kidney transplantations, 119 (7.6%) had symptomatic VUR treated with bulking agent. 35 (29.4%) had Deflux™ failure and were addressed to UR: 21/35 (60%) NPUS and 14/35 (40%) UNC. The median estimated blood loss, operative time, and length of stay were 120 mL, 90 min, and 7 days, respectively. After a median follow-up of 7.1 (IQR 4.1–9.8) years, UR was clinically successful in a total of 32 patients (91.4%): 20 (95.2%) and 12 (85.7%) patients in the NPUS and UNC groups, respectively (p = 0.55). Three (8.5%) high-grade complications have been reported. No nephrectomy of native kidney was required in the NPUS group. After failure of Deflux™ for VUR of renal graft, surgical treatment with native ureteropyelostomy or ureteroneocystostomy is associated to a high success rate and few high-grade complications.

Background We evaluated the range of prosthetic size-to-weight ratio to optimize valve survival in small children. Methods A single-institution retrospective review of mechanical mitral valve replacements from 1995 to 2019 was performed. Prosthetic valve size-to-weight ratio was calculated as the prosthetic valve diameter divided by the patient’s operative weight in children less than or equal to 35 kg. Patient death or reoperation on the valve was analyzed by size-to-weight ratio. Identifying a U-shaped distribution of events, patients were stratified as being in the nadir of the distribution or on the edges. Results Mechanical mitral valve replacements were performed in 56 (75%) children weighing less than or equal to 35 kg. Median follow-up time was 3.7 (interquartile range, 0.46-12) years. Median size-to-weight ratio was 1.5 (interquartile range, 1.0-2.0). A second replacement was required in 15 (27%) patients. Death occurred in 6 (11%) patients, including 3 after reoperation. The nadir of U-shaped distribution of events by size-to-weight ratio was bounded by a ratio from 1 to 2, which included 29 (52%) patients. A size-to-weight ratio from 1 to 2 provided optimal outcomes regardless of patient age. Reoperation-free survival at 5 years was 96% for patients with a ratio from 1 to 2 and 46% for patients with a ratio less than 1 or greater than 2. Patients with size-to-weight ratio 1 to 2 had longer reoperation-free survival than patients with a ratio less than 1 or greater than 2 (P Conclusions Regardless of patient age, in patients less than or equal to 35 kg, optimal reoperation-free survival after prosthetic mitral valve replacement can be obtained by placing a prosthetic valve whose diameter is between 1 and 2 times the patient’s weight in kilograms.

Objectives: This study aims to evaluate the clinical results and experiences in a community hospital regarding procedures for the replantation and revascularization of fingers. Patients and methods: Between June 2015 and December 2019, a total of 58 patients (51 males, 7 females; mean age: 33.4±6.3 years; range, 23 to 46 years) who were followed after total and/or subtotal amputation and replantation were retrospectively analyzed. The patients were evaluated at nine months in terms of cold intolerance, static two-point discrimination, and functional results using the range of motion (ROM) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Results: The majority of the patients presented with work-related injuries (70%), most commonly by the mechanism of guillotine (64%), and to the dominant hand (76%) and the third finger (36%) most frequently. The overall success rate of digit salvage was 72.9% (n=51). Of 19 digits with unsuccessful surgical outcomes, seven were from total and 12 were from subtotal amputations. In the long-term, cold intolerance was observed in 14 patients (24.1%) according to the cold intolerance severity scale. The mean static two- point discrimination value was 6.0±0.7 mm and the mean QuickDASH score was 22.3±5.0. The mean ROM measured at nine months after surgery in the metacarpophalangeal and interphalangeal joints of the third and fourth digits was significantly lower than that in the others (p Conclusion: The predictors of survival of a replanted digit indicated in this study can be used as a guide and decision-making aid for any attempts for replantation.

Background: The gold standard of surgical intervention of vesicoureteral reflux (VUR) is open ureteral reimplantation with high success and low complication rates. However, in recent years, endosco...

Anomalous aortic origin of the right coronary artery is a rare disease. Although there are various reports on its treatment, the method of the surgical approach is still controversial. Here, we present a rare case of a 17 year-old man who had an anomalous aortic origin of the right coronary artery with an aberrant right subclavian artery. As a treatment, he underwent reimplantation of the right coronary artery. The surgical approach for the anomalous aortic origin of the right coronary artery should be selected by considering the age of the patient and size of the right coronary artery.

Circumcision using a disposable stapler is becoming quite popular in China. However, improper surgical procedures also bring the risk of penile glans amputation, which is a very rare iatrogenic genital injury. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery. However, these may lead to obvious unfavorable outcomes such as amputated glans loss, necrosis, malformation healing, or urethral orifice stenosis. In the present study, we adopted microscopic replantation as an emergency approach to achieve the precise anastomoses and anatomic reconstruction of penile glans. The goal of this protocol is to present a detailed emergency management strategy with meticulous surgical skills for the penile glans amputation. The postoperative results showed that the original shape of the glans was perfectly restored with satisfactory cosmetic appearance. The micturition function was completely restored to normal without any obvious complications. There was also no significant reduction in the sensation of amputated glans area. Hence, early meticulous microscopic replantation as soon as possible is an ideal emergency management strategy for the penile glans amputation due to circumcision.

The study aimed to provide a guideline for continuous rehabilitation nursing for patients with severe finger replantation, and establish a satellite contact point for patients with severe finger replantation after discharge, so as to ensure scientific and effective rehabilitation training after discharge and explore the role of continuous rehabilitation nursing measurement in severe finger rehabilitation and neurovascular preservation.A total of 380 patients accepting neurovascular preservation finger replantation in the hand surgery department were divided into an observation group and a control group according to the number of hospitalizations. All patients underwent reconstructive surgery of severed finger. X-ray filming was used to monitor the postoperative nursing effect of neurovascular preservation of severed finger. The discharged patient information questionnaire was filled 3 days before the discharge. Then, a patient information database was established, and rehabilitation training was performed. Finally, sexual rehabilitation nursing follow-up intervention, telephone follow-up, and cross-referring intervention were carried out. Postoperative x-ray images were taken regularly to observe the recovery of reconstructed finger.There was no difference in daily life ability scores and hand function scores between the 2 groups at discharge (P0.05). The daily life ability scores and hand function scores of the observation group were better than those of the control group at 1 and 6 months after discharge (P0.05), the difference is statistically significant. As the discharge time prolonged, the daily life ability score and hand function score of the 2 groups of patients gradually increased. X-ray images showed that the replanted finger body was well developed, phalanx was in good antithesis, and there was no epiphysis.Continuous rehabilitation nursing measures should be taken after the replantation of the severed finger after neurovascular preservation, which provides standardized rehabilitation training standards for patients with replantation of severed finger after discharge, improves patient training compliance, promotes hand function recovery as soon as possible, and enables patients to return to society as soon as possible, which is worthy of clinical promotion and application.

Background Anomalous origin of one pulmonary artery from the ascending aorta (AOPA) is a rare and potentially deadly anomaly. Little research, aside from case reports on APOA, has been published, especially for patients with late referrals. Methods This study was a retrospective review of 57 patients with AOPA who underwent reimplantation of the pulmonary artery (PA) from 2009 to 2019. Two different reimplantation methods were used to correct the anomaly, including direct anastomosis in 36 patients and angioplasty with autologous tissue in 21 patients. Results The median age at repair was 2.8 months (range, 8 days to 3.6 years). In-hospital death occurred in 2 patients (3.5%). Five patients (9.1%) with a median age of 9.3 months (range, 5.2 months to 3.6 years) experienced a pulmonary hypertensive crisis. Patients older than 4.9 months were more likely to have a pulmonary hypertensive crisis (P = .001). The 2-year freedom from postoperative PA stenosis rate was 75.3% in patients who underwent direct anastomosis and 46.8% in patients who underwent autologous tissue angioplasty (χ2 = 4.878; P = .027). Angioplasty with autologous tissue (hazard ratio, 5.03; 95% confidence interval, 1.61 to 15.71; P = .005) and an innately smaller diameter of the aberrant PA (hazard ratio, 0.65; 95% confidence interval, 0.45 to 0.92; P = .015) were 2 independent risk factors for postoperative PA stenosis. Conclusions Surgical reimplantation of the PA in patients with AOPA has resulted in favorable early and midterm outcomes. Pulmonary hypertensive crisis occurs more commonly in patients who receive a diagnosis after the age of 4.9 months. Reimplantation with autologous tissue augmentation and an intrinsically smaller diameter in affected PAs are 2 independent risk factors for postoperative PA stenosis.

Introduction: According to the Urology guidelines, in selected cases of distal upper tract urothelial carcinoma (UTUC) segmental ureterectomy (SU) can be offered. There is no consensus in the surgical technique of preference. Robot-assisted SU could be an option to overcome all the limitations of open and laparoscopic techniques. We describe our first experience of robot assisted SU with psoas hitch ureteral reimplantation (RAPHUR). Materials and methods: 11 patients underwent RAPHUR for distal UTUC between 2013 and 2017 in a single centre. Pre-, intra-, and postoperative outcomes were assessed. Conventional imaging was performed after 1, 3, 6 months and 1 year from surgery as follow up protocol. We retrospectively evaluated the technical feasibility, oncological and functional outcomes. Results: Median age was 71 years (57-91). The median length of the ureteral defect was 23 mm (10-40). Median preoperative creatinine level was 1.22 mg/dl (0.7-1.85) and median eGFR was 57.5 ml/min/1.73m2 (31-80). Five (45.5%) patients were symptomatic and 7 (63.6%) had hydronephrosis. Median operative time was 185 min (120-240), with a median blood loss of 100 ml (50-300). No case required conversion to open surgery. Overall, only 1 (9%) patient developed Clavien Dindo ≥ 3 postoperative complications. Average hospital stay was 7 (2-9) days. Mean postoperative creatinine was 1.05 mg/dl (0.8-1.85) and mean postoperative eGFR was 72 (36-83). During a median follow up time of 25.5 months (12-53), 4 (36.4%) patients experienced recurrence of urothelial cancer at conventional imaging follow up and 2 (18.2%) died due to its progression. Conclusions: In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma with optimal perioperative and functional outcomes. However, cancer control may be undermined compared to nephroureterectomy. Thus, further prospective studies are needed to confirm our findings.

Objective To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure. Methods Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019. Results A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group. Conclusion We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.

Background/aims Decoronation offers one of the best and most predictable clinical outcomes for dentoalveolar ankylosis. The aim of this study was to determine the factors associated with the efficacy and psychological impact of decoronation for bone preservation. Materials and methods The study included 42 paediatric patients with 42 infrapositioned replanted permanent teeth. Twelve of these teeth were decoronated. Variables such as the time of injury, stage of root development and the extent of infraposition were analysed. The vertical changes in the alveolar bone level of the decoronated teeth were assessed on radiographs using a three-point scoring system. Parents of 30 patients with teeth that were not decoronated completed a questionnaire addressing their considerations and concerns regarding the treatment of infraposition. Results Teeth with root development in stages 2 and 3 showed a significantly higher rate of severe infraposition during the follow-up visits. Decoronation was performed on 12 teeth within 1.5-5 years (mean 3.8 ± 1.3 years) after replantation and 11 of these cases developed a considerable alveolar bone level. The alveolar bone levels of boys and girls showed improvements of 2.2 and 3.2 mm, respectively. The optimal age for decoronation to have a considerable increase in bone level was 12.12 ± 0.83 years for boys and 11.25 ± 1.77 years for girls. Complicated treatments, followed by parents' lack knowledge regarding decoronation, children's fear, follow-up times, and cost were the major concerns regarding decoronation. Conclusion The optimal time for decoronation should be decided after considering the age, gender, skeletal growth pattern, and the degree of infraposition at the time of decoronation.

Objectives: To evaluate the early and late outcomes of the modified Bentall procedure with the flanged technique. Methods: We reviewed the medical records of 63 patients who had undergone root replacement by the modified Bentall procedure at our institute between January 2001 and December 2018. In most cases, we adopted a composite graft constructed with a mechanical valve or bioprosthesis and a Dacron graft by the flanged technique. Since 2011, we have used Valsalva grafts. Results: Mean age 57 ± 16 years, range 16-80, male 43 cases. The mean follow-up was 75 ± 56 months (range 0-216). Through April 1, 2020, we could follow up on 61 cases (97%) within a six-month period. Hospital mortality was 7.9% (4.8% in elective cases). In late follow-up, eight deaths were observed. In the bio-Bentall group (n=26), no deaths or major adverse valve-related events (MARVEs) occurred. In the mechanical Bentall group (n=37), seven cases of MARVEs, including two cerebral hemorrhages and one cerebral embolism, were observed. All patients were free from MARVEs at 5 years post procedure in the bio-Bentall group, and 93.8% and 76.8% were event-free at 5 years and 10 years, respectively, in the mechanical Bentall group. Conclusions: The 18-year results of the modified Bentall procedure were acceptable, providing excellent outcomes in the bio-Bentall group. The flanged technique enabled the use of a larger prosthesis, which may have resulted in good durability with the bio-Bentall procedure.

W pracy przedstawiono podsumowanie działalności Serwisu Replantacyjnego dla amputacji rąk w Polsce w latach 2017-2019. W analizowanym okresie, do Serwisu zgłoszono 551 przypadków amputacji i innych rozległych urazów kończyn górnych, z czego 330 zaakceptowano do operacji, a w 221 przypadkach, z różnych powodów odmówiono przyjęcia. Wśród 330 przyjętych było 165 (50%) amputacji całkowitych, 131 (40%) prawie całkowitych i 34 (10%) inne, ciężkie, zagrażające utratą kończyny urazy. W przeważającej liczbie ofiarami byli mężczyźni w młodym i średnim wieku. Najwięcej było amputacji kilku palców i kciuków - 251 (76%), następnie amputacji na poziomie śródręcza - 30 (9%), przedramienia - 23 (7%) i nadgarstka - 20 (6%). U 138 chorych (42%) z całkowicie amputowanymi kończynami lub palcami wykonano replantację, u 98 (30%) rewaskularyzację, a u 45 (14%) naprawę rozległych uszkodzeń (pierwotna rekonstrukcja). W 26 przypadkach (8%) wykonano pokrycie ubytków płatami, a w 23 (7%) nie podjęto próby replantacji i zaopatrzono kikut kończyny. Przeżywalność replantowanych i rewaskularyzowanych części kończyn wynosiła śr. 65% dla replantacji i 85% dla rewaskularyzacji. W porównaniu do raportu z okresu 2013-2016, liczba leczonych chorych była podobna, ale inna była struktura urazów: więcej było przypadków amputacji palców - o 22, za to znacznie mniej - o 50 amputacji proksymalnych: ręki, przedramienia i ramienia. Przedstawiony raport podkreśla znaczenie nieformalnej struktury, jakim jest Serwis Replantacyjny w ratowaniu kończyn ciężko okaleczonych pacjentów., This article summarises activity of the Replantation Service for hand amputations in Poland in years 2017-2019. Over this period a total of 551 cases of total and subtotal amputations as well as other complex injuries to the hand were referred to the referenced centres. Of these, 330 referrals were accepted and 221 rejected, for various reasons. Among these accepted, there were 165 total (50%) and 131 subtotal (40%) amputations; 34 patients (10%) had other severe hand injuries. Vast majority of the patients constituted young and middle-age males. The most common was amputation of several digits and thumbs - a total of 251 cases (76%), followed by transmetacarpal - 30 (9%), forearm - 23 (7%) and wrist - 20 (6%) amputations. Replantation of amputated extremity was performed in 138 patients (42%), revascularization in 98 (30%) and in 45 (14%) primary repair of the complex injuries. In 26 cases (8%), coverage of tissue defects was performed, and in 23 (7%) primary terminalization. Survival rate was of a mean of 65% for replantations and 85% for revascularizations. Comparing to the previously reported period 2013-2017, the number of treated patients was similar, but structure of injuries differed: number of digital amputations increased (of 22 cases), whereas number of proximal amputations (hand, forearm and arm) significantly dropped (of 50 cases). The importance of Replantation Service, an informal structure, in saving limbs of severely mutilated patients was emphasised.

Background: Valve-sparing aortic root replacement (VSARR) techniques are an alternative to the classic Bentall procedure when aortic root aneurysm is not accompanied by aortic valve stenosis, and the regurgitant aortic valve is amenable to repair. Aims: The aim of the study was to assess long -term outcomes of valve sparing aortic root replacement using the David technique and the Yacoub technique. Methods: A total of 101 consecutive, elective VSARR procedures were performed from January 2010 to April 2020 including 52 David procedures (51.5%) and 49 Yacoub procedures (48.5%). We analyzed mortality, freedom from reoperation, and freedom from aortic valve regurgitation. The analysis was performed for the entire study cohort and for 2 subgroups: the David technique and the Yacoub technique. Results: The mean (SD) age was 50.2 (16.1) years; 90 (89.1%) patients were male. The median (interquartile range [IQR]) EuroScore II was 3.7 (2.7‒5.8). At 1, 5, and 8 years after surgery, survival (SE) was 98% (3%), 91.8% (8%), and 91.8% (8%), respectively, whereas freedom from reoperation (SE) was 100%, 97% (3%), and 97% (3%), respectively. Follow‑up echocardiography performed at a median (IQR) of 18.7 (2.5‒36.7) months postsurgery revealed freedom from aortic valve regurgitation in 90.8% of patients. No significant differences in mortality, freedom from reoperation, and freedom from aortic valve regurgitation were noted between the David and Yacoub subgroups. Conclusions: VSARR is a safe and effective surgical technique in patients with aortic root aneurysm, as the associated mortality, reoperation rate, and aortic valve regurgitation recurrence are low.

Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium–long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience.

Effects of cranioplasty (CP) and skullcap reimplantation after decompressive craniectomy (DC) for cerebral hemorrhage or malignant brain infarction in patients with left ventricular assist device (LVAD) support as bridge to transplantation has not been surveyed yet. The aim of this study was to evaluate outcome and management after CP when aiming for transplantation. Data were collected from our prospective institutional database including all patients undergoing LVAD implantation between 2010 and 2019. Six patients needed CP procedures and were included. Our analysis focused on postoperative outcome, survival, and facilitation of heart transplantation. Study endpoints included also all-cause mortality. From a total of 1010 LVAD implantations during analysis period in our center, six bridge-to-transplantation LVAD patients [median age at LVAD implantation: 32.5 years (IQR: 24.8-39.5 years); four male, HVAD, n = 3; HM II, n = 1; HM 3, n = 2] underwent CP with imminent entrapment secondary to cerebral hemorrhage or malignant infarction. Primary heart failure etiology was myocarditis (n = 2), dilated (n = 2), or ischemic (n = 2). Median INTERMACS class was 1.5 (IQR; 1.0-2.8). Median time on LVAD support to DC procedure was 33 months (IQR: 16-48 months). The indication for DC was intraparenchymal hemorrhage (n = 4), subdural hematoma (n = 1), and malignant middle cerebral artery infarction (n = 1). After a median time of 4 months (IQR: 3.3-4.0 months, range; 2.0-10 months) post DC procedure, CP was subsequently performed without profound neurologic disabilities in all patients. After median time of 26 months (IQR: 21-42 months) follow-up, three patients successfully received heart transplantation, one patient could undergo LVAD explantation for myocardial recovery, and the remaining two patients are still on the list awaiting heart transplantation. CP procedure with skullcap reimplantation is feasible and can be safely performed in LVAD patients, which subsequently may even be eligible for heart transplantation with beneficial prognosis.

Introduction : Thumb replantation following complete amputation is a relatively frequent and well-established surgical procedure. In literature many studies report a discrepancy between the objective measurements and the subjective satisfaction of the patients. Nowadays, evaluation of the patient long-term benefit obtained by replantation is uncertain. The aim of this study was to consider the long-term results of 33 thumb replantation procedures. Methods : The period considered is from January 1997 to December 2015, 33 subjects fulfilled the study inclusion criteria and were included in the study. We evaluated in each patient: ROM (performing Kapandji test), level and mechanism of amputation, force peak of three grips using Dexter dynamometer (five-handle, key, tri-digital grips), sensibility (using Disk-Criminator and aesthesiometers of Semmes-Weinstein) and subjective perception of disability (using DASH questionnaire). Results : All patients were males, 94% of them returned to their previous occupation. Average follow-up was 9±4 years. The prevalent mechanism of injury was a combined amputation in 58% of cases. Levels involved in more than half of patients were interphalangeal joints and proximal phalanxes. Ratios of strength recovery were: for the five-handle grip equal to 0.90±0.28 kg (p=0.63), 0.78±0.30 kg (p=0.64) for key grip and 0.75±0.32 kg (p=0.78) for tri-digital grip. Results for Kapandji test was 8±2 and for DASH test was 16±21. The protective tactile threshold was recovered in 49% of patients; S2PD test resulted positive in 54% and D2PD test in 39% of cases. Conclusions : Results confirm and strengthen evidence of positive long-term functional outcomes of thumb replantation interventions.

This study evaluated the feasibility and durability of the modified Cabrol coronary reattachment technique after aortic root replacement.The study retrospectively reviewed 370 patients who underwent aortic root replacement, during 1991 and 2018, and who were separated into 2 groups: a modified Carol (mCabrol) group (n = 84), consisting of patients with 1 or both coronary ostia reimplanted using a modified Cabrol technique; and a Carrel group (n = 286), consisting of patients with both coronary ostia reimplanted using the Carrel button technique.Baseline characteristics were similar in the 2 groups, except the mCabrol group had higher rates of redo sternotomy (74% vs 16%), chronic aortic dissection (58% vs 19%), and infection (14% vs 3%). In the mCabrol group, 60% had both coronary arteries reattached with the technique, and 40% of the procedures were unilateral. Operative mortality was significantly higher in mCabrol group compared with the Carrel group. However, in the stratified analysis for resternotomy, operative mortality between 2 groups were similar (16% vs 13%; P = .786). The survival rate at 5 years and 10 years was 68 ± 6% and 44 ± 6%, respectively, in the mCabrol group and 87 ± 2% and 80 ± 3%, respectively, in the Carrel group (log-rank P.001). After propensity adjustment, chronic kidney disease and prior coronary artery bypass grafting, but not the modified Cabrol technique, were independent predictors of both operative mortality and follow-up mortality (operative, P = .518; follow-up, P = .080). A total of 47 (66%) of 71 discharged patients in the mCabrol group had follow-up imaging, and no Cabrol graft was occluded. Two patients in the mCabrol group required interventions related to the reattachment technique: 1 coronary ostial anastomosis stenosis and 1 graft-to-graft anastomosis pseudoaneurysm.The modified Cabrol reattachment technique was not predictive of increased mortality and has excellent patency.

Background Bone distraction lengthening has been used for hand reconstruction. The healing process involved in this technique is affected by many factors. Here, the effectiveness and rates of healing of the phalanges and the metacarpals were evaluated in cases of traumatic finger amputation treated using an Ilizarov mini-fixator. Methods Fourteen phalanges and twelve metacarpals in 15 patients (13 males and 2 females) were treated with distraction lengthening using an Ilizarov mini-fixator between 2014 and 2017. All the digits had been subjected to traumatic amputation, and shortening of the remaining digit had occurred despite successful replantation in some cases. The healing indices of phalanges and metacarpals were analyzed. Results The mean patient age was 42.8 years. The mean lengthening of the phalanges was 13.3 mm, while that of the metacarpals was 26.5 mm. The mean consolidation times were 144.4 days for the phalanges and 154.1 days for the metacarpals. The mean healing indices of the phalanges and metacarpals were 114 days/cm and 60 days/cm, respectively. No bone grafts were needed in any of the patients. Conclusions Distraction lengthening of the digits after traumatic amputation is an effective procedure for hand reconstructive surgery for either the phalanges or the metacarpals and is less invasive than other techniques. The rate of healing of the metacarpals is two times faster than that of the phalanges.

Infection after total knee arthroplasty (TKA) is a rare but devastating complication. Different types of spaces have been used in two-stage revision. The study aimed to evaluate the effect of autoclaved femoral and tibial components as spacers for treating periprosthetic infections after TKA.A retrospective study was performed for 13 patients (five males, eight females) with a mean age of 69 ± 6 (range, 57-80) years and suffering from periprosthetic infection after TKA. They were treated with unconventional two-stage revision from May 2008 to June 2017. In the first-stage surgery, the autoclaved femoral and tibial components were reimplanted with a new liner as a spacer after a thorough debridement. After 4-6 months, the second-stage surgery was performed according to the patients' requirements. The knee society score (KSS) and knee range of motion (ROM) were assessed before and after surgery. The reinfection rate was calculated.The mean duration of follow-up was 5.7 ± 2.1 (range, 3.1-8.8) years. Culture-positive infections comprised 69% of the cohort. All patients were able to walk 24 h after the first stage surgery, and the knee ROM could reach 90° in 1 week. Two patients (15.4%) experienced an infection recurrence. One patient was reinfected 1 year after the first stage surgery. Another patient developed reinfection 3 years after surgery but did not choose re-revision and died of pneumonia. Only one patient underwent the second stage revision. The remaining 10 patients refused to receive a new prosthesis. At the time of the final follow-up, six patients had slight pain in the knee while walking, and one patient required crutches to walk. There were no signs of prosthesis dislocation, rupture, deep vein thrombosis, pulmonary embolism, or delayed wound healing. No radiolucent lines or osteolysis were found. The mean KSS improved from 51 ± 10 (range, 35-63) points preoperatively to 79 ± 5 (range, 60-85) points at the final follow-up. The average ROM before and after the first stage surgery were 62° ± 29° (range, 10°-100°) and 104° ± 9° (range, 90°-120°) (t = 4.659, P 0.01) respectively. The infection control rate was 84.6%.Reimplantation of the autoclaved original femoral and tibial components as an articulating spacer during the first stage surgery is a valuable addition for treating an infected TKA.

The eCoin (Valencia Technologies Corporation, Valencia, CA) is a battery-powered, nickel-sized and shaped neuromodulation device for the treatment of overactive bladder, and it is implanted in the lower leg in a short office or outpatient procedure under local anesthesia. A follow-on trial was conducted to evaluate the feasibility, safety, and efficacy of eCoin reimplantation.This was a prospective, single-arm, open-label study, including 23 participants with refractory urgency urinary incontinence (UUI) who were previously participants in the eCoin clinical feasibility trial. This follow-on study was conducted at 7 sites in the United States and New Zealand. Participants were reimplanted with a new eCoin device and activated after 4 weeks. Bladder diary data and validated quality-of-life instruments, collected at 12 weeks and 24 weeks postactivation, were compared with baseline.Participants of the study were considered responders if they reported a ≥ 50% reduction from baseline in episodes of UUI on a 3-day voiding diary. At 12 weeks of treatment, 74% (95% confidence interval [CI], 52%-90%) of participants were considered responders. At 24 weeks of treatment, 82% (95% CI, 60%-95%) of participants were considered responders with 36% (95% CI, 20%-57%) of participants achieving complete continence. There were no device-related serious adverse events reported during the study.The reimplantation of eCoin was both safe and effective in treating UUI associated with overactive bladder syndrome. The demonstrated significant reduction or resolution of symptoms with no serious safety concern suggests that eCoin is a convenient and maintainable therapeutic device.

Congenital ureterovesical junction (UVJ) obstructions quite rarely serve as an indication for ureteral reimplantation, and recurrent obstructions resulting from surgical treatment are even less frequent. Cases of acquired UVJ obstruction following endoscopy and ureteral reimplantation done for vesicoureteral reflux correction are fairly rare. The lack of known publications analyzing treatment of recurrent obstructive megaureter predetermines topicality of our research.Evaluate the efficiency and safety of extravesical anti-reflux uretero-cysto-anastomosis performed using Bradis technique for children with recurrent obstructive megaureter (OM).The work is based on the experience of surgical OM correction in 5 children aged 1 to 4 years, 4 boys and a girl with a recurrent UVJ obstruction following prior ureteral reimplantation for correction of UVJ obstruction (4 children) or vesicoureteral reflux (1 patient). Antenatal UVJ obstruction had been diagnosed in 2 patients. In all cases the examination included urine analysis, its culture study, ultrasonography of the kidneys and urinary tracts, dynamic renal scintigraphy, micturating cystography, and, where indicated, intravenous urography and SCT of the kidneys. All patients underwent Bradis extravesical reimplantation.During postoperative care period, a considerable reduction of the dilatation of renal collecting system was accomplished in all five patients along with the differential renal function preserved on the pre-surgery level and a steady remission of urinary tract infection based on clinical manifestations and laboratory findings.The simplicity of Bradis extravesical ureteral reimplantation represents its advantage over intravesical methods. Extravesical approach allows easy ureteral length and width correction. Limited experience of Bradis surgery in pediatric cases of recurrent OM requires confirmation with further randomized clinical trials.

Objectives: Previous data on the trends of surgical treatment of vesicoureteral reflux outside USA are scarce. The aim of this study was to clarify the national trends of operative treatment of vesicoureteral reflux (VUR) in Finland. Methods: We analyzed national data from Finnish Care Register for Health Care on children ( Results: Endoscopic injections of the ureteral orifices were primarily performed for 1212 and open ureteral reimplantation for 272 children. The use of both types of surgery decreased during the study period (p = 0.0043 and p

Objective The aim of this study was to analyze the outcomes of revision surgery following replantation of single digital amputations. Methods In this study, first, a total of 403 patients (339 male, 64 female; mean age=28 years; age range=1-76) in whom a single finger replantation was performed were retrospectively reviewed, and then 60 patients with arterial or venous insufficiency in whom revision surgery was performed were reanalyzed. The second finger was observed to be the most injured one (32.8%). Injury type was classified as clean cut (25.3%), local crush (38.7), extensive crush (7.9%), and avulsion (28.1%). When taking the levels of injuries of the artery-only finger replantations into account, one finger (0.8%) was nail distal third, 70 fingers (56%) were nail distal third to lunula, 43 fingers (34.4%) were lunula to distal phalanx basis, 10 fingers (8%) were distal interphalangeal (DIP) joint, and one finger (0.8%) was middle phalanx. Operative revision was performed on 60 (14.9%) fingers. The need for operative revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The average revision time was 43 (range=6-144) hours. While the average elapsed time for artery procedures was 35.3 (range=8-110) hours, the average elapsed time for vein procedures was 47.1 (range=6-144) hours. Finger survival rates were examined. Injury mechanism, amputation level, the number of artery/vein repairs and methods were examined in all patients and revision patients separately. Results After the replantations, according to survival analysis, while 342 (84.9%) fingers were operated upon successfully, 61 (15.1%) fingers developed necrosis. In the patients with revision surgery, the survival rate was 78.3%. The need for revision was arterial insufficiency in 37 fingers (61.7%) and venous insufficiency in 23 fingers (38.3%). The revision rate was significantly lower than other injury types in clean-cut cases. In terms of levels of injury, no revisions were required from distal to lunula level, and the highest revision rate was observed at the proximal interphalangeal (PIP) joint level. Conclusion The results of the present study have shown that early re-exploration can provide a 78.3% success rate and can increase the survival rate from 67.6% to 84.2% following replantation of single digital amputations. Surgical re-exploration seems to be a reasonable salvage for replanted fingers with vascular insufficiency. Level of evidence Level IV, Therapeutic study.

Aim: Vesicoscopic Cohen's reimplantation closely replicates the open procedure and is reported to have equally good results. Robotic assisted vesicoscopic reimplantation (RAVR) is a new procedure, ...

Pulmonary artery sling (PA sling) often presents as a life-threatening condition requiring urgent surgical correction. We reported 32 cases of PA sling in children who were followed up postoperatively in the past 6 years. All patients with PA slings who were admitted to the hospital from January 2012 to December 2017 and underwent surgery were retrospectively analyzed. The mean age of the 32 patients at repair was 16.97 months (range, 15 days to 128 months). Six patients required ventilator assistance for respiratory failure. All children underwent left pulmonary artery (LPA) reimplantation (n = 32), and 3 patients needed reimplantation slide tracheoplasty (n = 3) due to ventilation weaning failure. Four patients died, 27 patients survived until discharge, and 18 patients were followed up. Pulmonary computed tomography imaging and echocardiography were performed in 18 patients who were followed up. After LPA reimplantation, the tracheal carina area was significantly enlarged compared to that preoperation (p = 0.0002). In this follow-up cohort study, 75% of the patients who underwent LPA reimplantation survived until discharge. The survivors had subsequently well-developed pulmonary arteries and tracheas.

Background Multilevel dysvascular injury of the hand can be treated with replantation or revision amputation. The authors compared both modalities regarding functional outcomes, patient-reported outcomes, and required resources, as relevant studies are scarce. Methods In this retrospective review of consecutive case series (replantation, n = 8; revision amputation, n = 11), clinical results and functional outcomes (including grip strength, range of motion, sensory recovery, and grip or pinch ability) were assessed. Patient-reported outcomes, required hospital resources, and treatment cost until 1 year after surgery were compared between both groups. Results Six patients used passive prostheses, two used body-powered prostheses, and three did not use a prosthesis in the revision amputation group. All patients in the replantation group could grip objects and had restored hands, with protective sensory recovery and substantial wrist motion, whereas six patients in the revision amputation group were unable to grip or pinch objects. Replantation was associated with superior patient-reported outcomes, but required more hospital resources and treatment costs. Conclusions This study suggests that in the treatment of multilevel dysvascular injury of the hand, the surgical method should be chosen on a case-by-case basis. For better functional and patient-reported outcomes, replantation is preferred. Revision amputation can be performed in the absence of sufficient hospital resources and to reduce treatment cost. These findings can aid in the preoperative counseling of patients with multilevel dysvascular injury of the hand. Clinical question/level of evidence Therapeutic, III.

Retention of the distal phalanxes is important in the treatment of multiple digit amputations in infants to preserve the digit length and nail for functional and cosmetic reasons. We report the case of a 22-month-old boy with multiple digit amputations of his left index, middle, and ring fingers, which were severely mangled and not suitable for replantation. We propose the usefulness of the abdominal pocket method combined with composite grafts of the amputated phalanxes and nails and report the outcome of our case, with 2-year follow-up.

Vasospasm is one of the important causes of morbidity in free flap and replantation surgery. In secondary Raynaud’s phenomenon, nearly half of the patients experience digital ulceration, pain and loss of function at least once in their lifetime. The aim of this study is to investigate the vasodilation effect of ethanol-mediated chemical denervation on peripheral vessels by topical administration. In this study, 27 Wistar albino male rats weighing 250-300 grams were used. The rats were randomly divided into three groups: saline (group S, n = 8), lidocaine (group L, n = 9) and 96% ethanol (group E, n = 9). According to group, 0.1 mL saline, 0.1 mL lidocaine and 0.1 mL ethanol were applied around the rat femoral neurovascular bundle. After the application, on the 0th day and 3th weeks, femoral artery and vein diameters were measured. After 3. weeks, histopathological samples from femoral artery, vein and nerve were evaluated. On the 0th day, the mean diameter of the femoral artery and vein was similar in group E and L and higher than group S. After three weeks, the vasodilatation effect of ethanol was increased in group E. In Group L and S, the vasodilatation effect was lost. Histopathological examination showed that ethanol significantly caused perivascular inflammation and nerve degeneration compared to other agents and did not cause endothelial damage. Vasodilatation obtained by ethanol is a rapid onset and long-lasting effect. It is also inexpensive and effective for peripheral vasodilatation.

Background The aim of this study was to compare the short- and long-term outcomes of patients who underwent aortic valve-sparing reimplantation (David) vs aortic root replacement (Bentall) operations in a propensity-matched analysis. Methods The study compared the data of propensity-matched patients who underwent David (n = 261) or Bentall (n = 262) procedures from 2000 to 2015. The mean age at surgery in the entire cohort was 53 ± 13 years, and 19.7% (n = 103) of the study patients were female. Connective tissue disease was present in 9.4% (n = 49) of patients, whereas 37.1% (n = 194) presented with a bicuspid aortic valve. Results The overall 30-day mortality was 1.1% (n = 6) and was not significantly different in patients with the David compared with the Bentall operation (0.4% [n = 1] vs 1.9% [n = 5]; P = .1). The 5- and 10-year survival rates were 93.7 ± 1.8% vs 93.8 ± 1.6% and 84.4 ± 4.7% vs 89.5 ± 3.2% for David vs Bentall, respectively (log-rank P = .98). Cox regression analysis identified age, smoking and previous cardiac surgery as independent predictors of long-term mortality. Freedom from reoperation did not significantly differ between patient groups (89.5 ± 3.4% vs 87.8 ± 4.1% 10 years postoperatively; log-rank P = .71). Bentall-treated patients had a higher rate of serious bleeding during follow-up (P = .025). Conclusions Both the David and Bentall operations are associated with excellent early and long-term results in patients with aortic root aneurysmal disease. The David operation is associated with less bleeding than the Bentall operation, without an increased risk of reoperation. Because of avoidance of bleeding and other long-term complications associated with prosthetic heart valves, the David operation is preferable to the Bentall operation in patients with appropriate pathoanatomy.

Objective To highlight the feasibility and technical details of performing simultaneous ipsilateral pyeloplasty and ureteric re-implantation for simultaneous proximal and distal obstruction of the ureter. Methods Two patients with preoperative diagnosis of proximal and distal ureteric obstruction underwent robot-assisted simultaneous pyeloplasty and ureteric re-implantation. The patients were placed in right lateral oblique position and pyeloplasty was performed in standard manner. In both cases, Double J stent could not be negotiated beyond the vesicoureteric junction into the bladder. The robot was dedocked and recentred around different ports to successfully perform uretero-neocystostomy over a 4.8 F double J stent. Results The mean operative times were 154 minutes with operative blood loss of approximately 50 ml. The postoperative convalescence was good in both cases and Double J stents were removed after 6 weeks. Follow-up diuretic renograms demonstrated stable renal function with unobstructed drainage. Conclusion Simultaneous repair of ipsilateral pelviureteric and vesicoureteric junction obstruction is safe and feasible contrary to traditional teachings. To the best of our knowledge this is the first description of robotic simultaneous pyeloplasty and ureteric reimplantation.

We experienced an extremely rare case of ureteral sextuplication with a blind-ending ureter originating from the upper pole. The patient had 6 separate ureters and 6 renal pelvises with 1 ureteral orifice on the left. The left kidney was hypoplastic and its differential function was 6.5%. The patient underwent definitive surgical treatment to repair the anomaly (ureteroureterostomy and reimplantation of the formed ureter). The surgery was successful and the postoperative course was uneventful. We herein report the first such case in the English-language literature and discuss the etiology of this ureteral anomaly, the method of diagnostic imaging, and the treatment.

Background: In this article, we report our experience on laparoscopic pneumovesical Cohen approach for vesicoureteral junction (VUJ) stricture in children and compared it with traditional open Cohen approach. Patients and Methods: Ninety-eight children (114 ureters) with VUJ stricture were involved in this study who were treated from January 2008 to December 2017. Forty-eight patients (56 ureters) treated with open Cohen approach from January 2008 to December 2011 were marked as Group 1 and 50 patients (58 ureters) treated with laparoscopic pneumovesical Cohen approach from January 2012 to December 2017 were marked as Group 2. The preoperative data, operative details, and follow-up outcomes were studied and compared between two groups to discuss the advantages of the laparoscopic pneumovesical approach. Statistical comparison was made with unpaired t-tests, χ2 tests, and Fisher exact probabilities, with P value

Background and importance Posterior inferior cerebellar artery (PICA) aneurysms are uncommon, and aneurysms associated with anatomical PICA variants are even rarer. Although often treated endovascularly, aneurysms associated with anatomical PICA variants may not be suitable for endovascular intervention because of the risk of compromise of brainstem perforators and may be more amenable to open techniques. This case report describes the successful treatment of an aneurysm associated with a double-origin PICA (DOPICA) by distally reimplanting one of the PICA limbs. Clinical presentation A 78-yr-old man with a Hunt-Hess grade III, Fisher grade IV subarachnoid hemorrhage secondary to a ruptured distal right PICA aneurysm associated with a DOPICA was treated with PICA-PICA bypass and trapping of the aneurysm. This is the first reported case in the literature of successful bypass of a DOPICA-associated aneurysm. Radiographically, the bypass remained patent with successful obliteration of the aneurysm, and at discharge from the hospital, the patient had a Glasgow Coma Scale score of 15 and modified Rankin Scale score of 3. Conclusion This case demonstrates a novel reimplantation bypass for a ruptured aneurysm that exploits this rare variant anatomy of a DOPICA.

The aim of this study was to summarize in a literature review our treatment experience involving microscopic replantation in a rare case of a completely amputated penis and testes. The penis and testes were completely amputated due to self-mutilation. The 26-year-old patient immediately underwent microscopic replantation of the penis and testes after pre-operative preparation. Potent anti-infectives and anti-depressives, and microcirculation-improving hyperbaric oxygen therapy were utilized after surgery. The time between the amputation and surgery was about 10 h. The patient was followed for 12 months post-surgery. The replanted penis recovered and the patient could urinate normally in the standing position with a maximal urinary flow rate of 20 ml/s. The testes also survived, but their size showed obvious atrophy. The serum testosterone level at 2 months after the operation was 120 ng/dL (normal reference range: 175–781 ng/dL). Erectile function gradually recovered after androgen replacement therapy. Complete amputation of the penis and testis is very rare. Efforts should be made to perform the replantation surgery as soon as possible. Microscopic surgical techniques for elaborate vascular and neural anastomosis constitute the basis for a successful replantation. Post-operative comprehensive treatment such as strong anti-infection, analgesia, anti-depression, improvement of microcirculation, and hyperbaric oxygen is crucial for the survival and functional recovery of replanted organs.