Establishing and clinically validating a machine learning model for predicting unplanned reoperation risk in colorectal cancer

BACKGROUND Colorectal cancer significantly impacts global health,with unplanned reoperations post-surgery being key determinants of patient outcomes.Existing predictive models for these reoperations lack precision in integrating complex clinical data.AIM To develop and validate a machine learning model for predicting unplanned reoperation risk in colorectal cancer patients.METHODS Data of patients treated for colorectal cancer(n=2044)at the First Affiliated Hospital of Wenzhou Medical University and Wenzhou Central Hospital from March 2020 to March 2022 were retrospectively collected.Patients were divided into an experimental group(n=60)and a control group(n=1984)according to unplanned reoperation occurrence.Patients were also divided into a training group and a validation group(7:3 ratio).We used three different machine learning methods to screen characteristic variables.A nomogram was created based on multifactor logistic regression,and the model performance was assessed using receiver operating characteristic curve,calibration curve,Hosmer-Lemeshow test,and decision curve analysis.The risk scores of the two groups were calculated and compared to validate the model.RESULTS More patients in the experimental group were≥60 years old,male,and had a history of hypertension,laparotomy,and hypoproteinemia,compared to the control group.Multiple logistic regression analysis confirmed the following as independent risk factors for unplanned reoperation(P<0.05):Prognostic Nutritional Index value,history of laparotomy,hypertension,or stroke,hypoproteinemia,age,tumor-node-metastasis staging,surgical time,gender,and American Society of Anesthesiologists classification.Receiver operating characteristic curve analysis showed that the model had good discrimination and clinical utility.CONCLUSION This study used a machine learning approach to build a model that accurately predicts the risk of postoperative unplanned reoperation in patients with colorectal cancer,which can improve treatment decisions and prognosis.

Radical cholecystectomy without liver resection for peritoneal side early incidental gallbladder cancer

Gallbladder cancer(GBC)is a rare disease with a poor prognosis.Simple cholecystectomy may be an adequate treatment only for very early disease(Tis,T1a),whereas reoperation is recommended for more advanced disease(T1b and T2).Radical cholecystectomy should have two fundamental objectives:To radically resect the liver parenchyma and to achieve adequate clearance of the lymph nodes.However,recent studies have shown that compared with lymph node dissection alone,liver resection does not improve survival outcomes.The oncological roles of lymphadenectomy and liver resection is distinct.Therefore,for patients with incidental GBC without liver invasion,hepatic resection is not always mandatory.

Readmission rate and early complications in patients undergoing total knee arthroplasty:A retrospective study

BACKGROUND Total knee arthroplasty(TKA)can improve pain,quality of life,and functional outcomes.Although uncommon,postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery.Identification of the risk factors for complications and readmissions after TKA,taking into account common causes,temporal trends,and risk variables that can be changed or left unmodified,will benefit this process.AIM To assess readmission rates,early complications and their causes after TKA at 30 days and 90 days post-surgery.METHODS This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1,2017,and February 28,2022.Of the 633 patients,28 were not contactable,leaving 609 who met the inclusion criteria.Both inpatient and outpatient hospital records were retrieved,and observations were noted in the data collection forms.RESULTS Following TKA,the 30-day and 90-day readmission rates were determined to be 1.1%(n=7)and 1.8%(n=11),respectively.The unplanned visit rate at 30 days following TKA was 2.6%(n=16)and at 90 days was 4.6%(n=28).At 90 days,the unplanned readmission rate was 1.4%(n=9).Reasons for readmissions included medical(27.2%,n=3)and surgical(72.7%,n=8).Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group(P=0.922),body mass index(BMI)(P=0.633),unilateral vs bilateral TKA(P=0.696),or patient comorbidity status(30-day P=0.171 and 90-day P=0.813).Reoperation rates after TKA were 0.66%(n=4)at 30 days and 1.15%(n=8)at 90 days.The average length of stay was 6.53 days.CONCLUSION In this study,there was a low readmission rate following TKA.There was no significant correlation between readmission rate and patient factors such as age,BMI,and co-morbidity status.

Reoperations for occluded arterial bypasses in the lower limbs

Background We reviewed the outcomes of reoperations for 29 patients （30 limbs） who had undergone occluded arterial bypass in the lower limbs from May 1996 to September 2005. Methods The 30 lower limbs of the 29 patients with arteriosclerotic obstruction received 44 reoperations, including thrombectomy alone （group T, 27） and inflow or outflow reconstruction plus thrombectomy （group C, 17）. Among the 17 operations in group C, 17.6% （3/17） were inflow reconstructions involving the axillary-femoral （1）, aorta-iliac （1） and aorta-femoral （1） arteries, and 76.4% （13/17） outflow reconstructions involving the femoral-popliteal bypass-tibial （8）, femoral-tibial （1）, femoral-popliteal bypass-popliteal arteries below the knee （2）, and the femoral-popliteal bypass-tibial-peroneal trunk （2）. One patient （1 limb） underwent both inflow and outflow reconstructions with an iliac arterial stent and a graft-popliteal anastomosis patch. Polytetrafluoroethylene （PTFE） grafts were used in the inflow or outflow reconstructions above the knee. Autovenous grafts or autovenously combined PTFE grafts were used in the outflow reconstructions below the knee. Results The percentages of Fontaine stage Ⅲ and IV before primary operation and reoperation were 60% （18/30） and 86.7% （26/30）, respectively （P〈0.05）. Four patients died of heart attack （2）, stroke （1） and multiple organ failure （1） after reoperations. Among them, only 1 patient underwent occluded bypass, and others, patent bypass. Five patients after patent bypass are still alive. The accumulative patent rate was 28.6% （8/28）. The average duration of patency in groups T and C was （4.16±5.68） （0.13- 24） months and （7.14±6.37） （0.26-21） months, respectively （P〉0.05）. Among 42 reoperations, 19 failed within 1 month in groups T （16） and C （3） （P〈0.01）. Nine patients had limb amputated （10/28 limbs, 35.71%） because of graft infection （2 limbs）, pseudo aneurysm at anastomosis （1 limb）, and gangrene caused by failed grafts （7 limbs）. The amputation was performed on 6 limbs within 1 month and on 4 limbs 1 month after reoperation （P〉0.05）. The rate of limb salvage was 64.29% （18/28）. Conclusions The percentages of Fontaine stageⅢ and Ⅳ before reoperation may be much higher than those before primary operation. Thrombectomy plus inflow/outflow reconstruction creates patency better than thrombectomy alone for re-occluded bypass.

Reoperation for heterochronic intraductal papillary mucinous neoplasm of the pancreas after bile duct neoplasm resection:A case report

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)and intraductal papillary mucinous neoplasm(IPMN)of the pancreas have similar pathological manifestations.However,they often develop separately and it is rare for both to occur together.Patients presenting with heterochronic IPMN after IPNB are prone to be misdiagnosed with tumor recurrence.CASE SUMMARY A 67-year-old male patient was admitted 8.5 years after IPNB carcinoma and 4 years after the discovery of a pancreatic tumor.A left hepatic bile duct tumor with distal bile duct dilatation was found 8.5 years ago by the computed tomography;therefore,a left hepatectomy was performed.The postoperative pathological diagnosis was malignant IPNB with negative cutting edge and pathological stage T1N0M0.Magnetic resonance imaging 4 years ago showed cystic lesions in the pancreatic head with pancreatic duct dilatation,and carcinoembryonic antigen continued to increase.Positron emission tomography showed a maximum standard uptake value of 11.8 in the soft tissue mass in the pancreatic head,and a malignant tumor was considered.Radical pancreatoduodenectomy was performed.Postoperative pathological diagnosis was pancreatic head IPMN with negative cutting edge,pancreaticobiliary type,stage T3N0M0.He was discharged 15 d after the operation.Follow-up for 6 mo showed no tumor recurrence,and quality of life was good.CONCLUSION IPNB and IPMN are precancerous lesions with similar pathological characteristics and require active surgery and long-term follow-up.

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism(pHPT)is the third most common endocrine disease.The surgical procedure aims for permanent cure,but recurrence has been reported in 4%-10%of pHPT patients.Preoperative localization imaging is highly valuable.It includes ultrasound,computed tomography(CT),single-photonemission CT,sestamibi scintigraphy and magnetic resonance imaging.The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months.Ongoing hypercalcemia during this period is defined as persistence,and recurrence is defined as hypercalcemia after six months of normocalcemia.Vitamin D is a crucial factor for a good outcome.Intraoperative parathyroid hormone(PTH)monitoring can safely predict the outcomes and should be suggested.PTH≤40 pg/mL or the traditional decrease≥50%from baseline minimizes the likelihood of persistence.Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology.Risk factors for recurrence are cardiac history,obesity,endoscopic approach and low-volume center(at least 31 cases/year).Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/recurrence.A 6-mo calcium>9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up.18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation.With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement,the recurrence rate has dropped to 2.5%-5%.Sixmonth serum calcium≥9.8 mg/dL and parathyroid hormone≥80 pg/mL indicate a risk of recurrence.Negative sestamibi scintigraphy,diabetes and elevated osteocalcin levels are predictors of multiglandular disease,which brings an increased risk of persistence and recurrence.Bilateral neck exploration was considered the gold-standard diagnostic method.Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques.Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence.Long-term follow-up,even up to 10 years,is necessary.

Erratum:Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

This is an erratum to an already published paper.We found an error in the results section and Table 1.Specifically,we have revised results with n≤10 to be reflected as such,which is consistent with the reporting instructions by the Agency for Healthcare Research and Quality.Please note,these changes do not affect our results,and we had previously listed this requirement in the results section.We apologize for our unintentional mistake.

Risk Factors of Reoperation and Outcome of Patients Operated for Chronic Subdural Hematoma in a Teaching Hospital in Rabat

Background: chronic subdural hematoma is a common pathology, especially in the elderly. Although it has a good prognosis, it poses the problem of recurrence after surgical evacuation. Objective: To analyze the risk factors of reoperation in patients surgically treated for chronic subdural hematoma (cSDH) and evaluate the outcome of patients who benefited from a reoperation. Materials and Methods: A retrospective review was conducted in a single University Hospital Center in Rabat (Morocco) on 49 patients operated on from January 2020 to June 2021 for cSDH. Possible risk factors described in the literature were analyzed and the outcome of post-operative course was evaluated. Statistical significance was defined by p-value Results: 49 patients underwent surgical evacuation of cSDH. The sex ratio of male/female was 3.08. The mean age was 70.6 years. Concerning the medical history, 8.2% were diabetics, 10.2% had heart disease, 18.4% had hypertension, 16.3% associated of comorbidities, 2% had pulmonary embolism, and 2% had neoplasm. 18.4% were on anticoagulation therapy, no patients were on new oral anticoagulants. The clinical findings upon admission were motor deficit at 57.1%, signs of intracranial hypertension at 20.4%, altered consciousness at 16.9% and impaired behavior at 6.1%. 28.6% of patients had a past history of head trauma. The pre-operative CT scan showed unilateral cSDH at 81.6%, midline shifts at 77.6%, and false membranes at 34.7%. Blood appeared chronic at 40.8%, subacute at 24.5%, and mixed densities at 34.7%. The post-operative course was uneventful in 73.5%. According to Ibanez grading 8 patients had mild complications (grade I) and 5 moderate complications (grade II) after the first surgery. We recorded 10.2% of patients who needed a second surgery because of the deterioration of neurologic status or motor deficit associated with an abnormal CT scan. According to the GOS, 85.7% of patients had a good recovery while 10.2% died. None of the factors assessed was found to be a risk factor for reoperation. Conclusion: No risk factors of reoperation after an initial burr hole evacuation for cSDH were found. However medical history and male sex was common condition among reoperated patients with their CT scan showing a chronic aspect of blood, midline shift and false membranes. Most patients who underwent revision surgery died on the postoperative course.

鼻内镜下再次鼻中隔矫正术

传统鼻中隔矫正术是在额镜反光照明下施行手术,照明度差,手术带有盲目性,加上手术器械本身的局限性及手术者的技术水平,鼻中隔矫正术失败的病例时有发现,原有症状未能解除或影响鼻腔其他疾病的治疗效果时,往往需要再次矫正。因手术视野小、术腔粘连严重，导致操作困难，再次手术的难度较首次明显增大。我科1997-2009年在鼻内镜直视下对34例患者实施了鼻中隔偏曲再次矫正术，效果满意，现报道如下。

Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital

AIM:To investigate the occurrence of postoperative complications of gastric cancer surgery,and analyze the potential causes of reoperation for early postoperative complications. METHODS:A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study.The study endpoint was the analysis of postoperative complications in inpatients. RESULTS:About 31%of patients had early postoperative complications,and complications of infection occurred most frequently.Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation,which accounted for about 2.2%.Mortality was 11.1%in the reoperation group,but was only 0.8%in other patients.The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation(P<0.001).There was no significant association of any available factors in this study with the high rate of reoperation.CONCLUSION:Reoperation significantly increases the mortality rate and raises the burden of the surgical unit.More prospective studies are required to explore the potential risk factors.

Reoperation of biliary tract by laparoscopy:Experiences with 39 cases

AIM:To evaluate the safety and feasibility of biliary tract reoperation by laparoscopy for the patients with retained or recurrent stones who failed in endoscopic sphincterotomy. METHODS:A retrospective analysis of data obtained from attempted laparoscopic reoperation for 39 patients in a single institution was performed, examining open conversion rates, operative times, complications, and hospital stay. RESULTS:Out of the 39 cases, 38 (97%) completed laparoscopy, 1 required conversion to open operation because of difficulty in exposing the common bile duct. The mean operative time was 135 min. The mean post-operative hospital stay was 4 d. Procedures included laparoscopic residual gallbladder resection in 3 cases, laparoscopic common bile duct exploration and primary duct closure at choledochotomy in 13 cases, and laparoscopic common bile duct exploration and choledochotomy with T tube drainage in 22 cases. Duodenal perforation occurred in 1 case during dissection and was repaired laparoscopically. Retained stones were found in 2 cases. Postoperative asymptomatic hyperamlasemia occurred in 3 cases. There were no complications due to port placement, postoperative bleeding, bile or bowel leakage and mortality. No recurrence or formation of duct stricture was observed during a mean follow-up period of 18 mo. CONCLUSION:Laparoscopic biliary tract reoperation is safe and feasible if it is performed by experiencedlaparoscopic surgeons, and is an alternative choice for patients with choledocholithiasis who fail in endoscopic sphincterectomy.

Sphincter of Oddi laxity:An important factor in hepatolithiasis

AIM:To evaluate the importance of sphincter of Oddi laxity (SOL) in hepatolithiasis (HL).METHODS:Subjects included 98 patients diagnosed with HL between 2002 and 2007. Detailed histories were taken and the subjects were monitored until July 2008. HL patients were divided into two groups:Group included 45 patients with SOL,and Group included 53 patients without. Recurrence and reoperation indices of both groups were calculated and compared.RESULTS:The recurrence index was 0.135 in Group and 0.018 in Group fldex was 0.070 in Group and 0.010 in Group (P <0.001). The mean frequency of biliary operation was 2.07in Group (P = 0.001). Differences between the two groups are significant.CONCLUSION:HL patients with SOL tend to have a higher risk of recurrence and a larger demand for re-operation than those without this condition.

Perianal disease,small bowel disease,smoking,prior steroid or early azathioprine/biological therapy are predictors of disease behavior change in patients with Crohn's disease

AIM:To assess the combined effect of disease phenotype, smoking and medical therapy [steroid, azathioprine(AZA), AZA/biological therapy] on the probability of disease behavior change in a Caucasian cohort of patients with Crohn's disease(CD).METHODS:Three hundred and forty well-characterized, unrelated, consecutive CD patients were analyzed(M/F:155/185, duration:9.4 ± 7.5 years) with a complete clinical follow-up.Medical records including disease phenotype according to the Montreal classification, extraintestinal manifestations, use of medications and surgical events were analyzed retrospectively.Patients were interviewed on their smoking habits at the time of diagnosis and during the regular follow-up visits.RESULTS:A change in disease behavior was observed in 30.8% of patients with an initially non-stricturing, non-penetrating disease behavior after a mean diseaseduration of 9.0 ± 7.2 years.In a logistic regression analysis corrected for disease duration, perianal disease, smoking, steroid use, early AZA or AZA/ biological therapy use were independent predictors of disease behavior change.In a subsequent Kaplan-Meier survival analysis and a proportional Cox regression analysis, disease location(P = 0.001), presence of perianal disease(P < 0.001), prior steroid use(P = 0.006), early AZA(P = 0.005) or AZA/biological therapy(P = 0.002), or smoking(P = 0.032) were independent predictors of disease behavior change.CONCLUSION:Our data suggest that perianal disease, small bowel disease, smoking, prior steroid use, early AZA or AZA/biological therapy are all predictors of disease behavior change in CD patients.

Reoperation for benign biliary tract diseases in 149 cases: causes and prevention

BACKGROUND: Failure to diagnose and treat benign bi- liary tract disease relatively common surgical disease may cause serious consequences. Since the introduction of B- mode ultrasonography, CT, or MRI early and accurate diagnosis of the disease has been possible. In clinical prac- tice, however, these methods have not been adequately used. Inappropriate surgical procedures can also lead to bile duct injury or stenosis after injury, residual cholecystitis, stenosis after cholangiojejunostomy, or stenosis of the Od- di' s sphincter. But improvement of the diagnosis and treat- ment of benign biliary tract disease remains a great chal- lenge to clinicians. METHODS: A total of 149 patients with benign biliary tract disease who had received reoperation from June 1988 to June 2001 were analyzed retrospectively. Among them 95 patients (63.76%) received operation twice and 38 (25.5%) underwent 3 operations. Sixteen patients (10.74%) needed 4 or more operations. The procedures for the first opera- tion included cholecystectomy (71 patients, 47.65%), cho- lecystectomy with exploration of the common bile duct (42, 28.19%), cholangiojejunostomy (21, 14.1%), and la- paroscopic cholecystectomy (15, 10.06%). RESULTS: The causes for reoperation included residual and recurrent bile duct stones in 53 patients (35.57%), bile duct injury or stenosis after injury in 41 (27.52%), residual cho- lecystitis with or without stones in 28 (18.8%), stenosis af- ter cholangiojejunostomy in 17 (11.41%), stenosis of the Oddi's sphincter in 5 (5.35%), and others in 5 (5.35%). Four patients (2.68%) died after operation. CONCLUSIONS: To prevent reoperation for benign biliary tract diseases, the following measures should be taken to in- crease preoperative diagnostic rate, to understand condi- tions of the biliary tract by using imaging techniques and cholangiography, to examine comprehensively and careful- ly with choledochoscopy, cholangiography and B-mode ul-trasonography intraoperatively, to choose appropriate ope- rative procedures to decrease the rate of residual stones, and to decide the time for the first repair according to inju- ry type of the bile duct. Roux-en-Y hepaticojejunostomy with cholangioplasty is the best operation for the recon- struction of the biliary tract.

Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth Ⅱ or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes:(1) entrapment, compression and kinking by postoperative adhesions;(2) internal herniation, volvulus and intussusception;(3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop;(4) cancer recurrence; and(5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluidfilled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes:(1) adhesiolysis and reconstruction for benign causes; and(2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.

Redo Coronary Artery Bypass Grafting: On-Pump and Off-Pump Coronary Artery Bypass Grafting Revascularization Techniques

Objective To analyze the short-term outcomes of redo coronary artery bypass grafting(CABG) using on-pump and off-pump CABG techniques. Methods From January 2003 to August 2013, non-randomized 80 patients were treated with redo CABG in the Department of Cardiac Surgery, Peking University Third Hospital. Among these patients, 40 underwent on-pump CABG technique(redo-ONCAB group) and 40 underwent off-pump CABG technique(redo-OPCAB group). Furthermore, transmyocardial laser revascularization was performed in high-risk patients who were not suitable to conventional grafting. Clinical data of the two groups were recorded and analyzed including operation time, coronary grafts, incomplete revascularization, postoperative ventilation, perioperative stroke, and low output syndrome, etc. Results There were no significantly differences in age, gender distribution, incidences of hypertension, stroke, and other clinical characteristics between redo-OPCAB group and redo-ONCAB group(all P>0.05), except for incidences of renal dysfunction and pulmonary disease(all P<0.05). The number of grafting vessels in the redo-ONCAB and redo-OPCAB groups was 2.1 ± 0.74 and 1.4 ±0.52 respectively. There was significant difference between the two groups(P=0.0243). Compared with the redo-ONCAB group, there was shorter operation time(P=0.0045), postoperative ventilation(P=0.0211) and intensive care unit stay(P=0.0400), as well as fewer use of platelet(P=0.0338) and blood transfusion(P=0.0034) in the redo-OPCAB group. The incidence of incomplete revascularization(P=0.0253) and the use of transmyocardial laser revascularization(P=0.0052) were higher in the redo-OPCAB group than those in the redo-ONCAB group(all P<0.05). However, no significant differences were showed for the incidence of the use of intra aortic balloon pump and continuous renal replacement therapy, perioperative stroke, low output syndrome, and in-hospital mortality between the two groups(all P>0.05). Conclusion Redo CABG is the safety and efficacy surgical procedure, and redo-OPCAB technique with better outcomes is commended especially in high-risk patients.

Characteristics of Postoperative Bleeding after Neck Surgery

Objective: To review the characteristics of and the procedure for preventing postoperative bleeding after neck surgery. Materials and Methods: A retrospective review of 9 patients (9/893;1.0%) with postoperative bleeding who required reoperation was performed to analyze clinical findings. Results: There was no significant difference in the incidence of bleeding between types of surgical procedures. Postoperative bleeding occurred within 24 hours in all cases except 2, in which it occurred 7 days or more after the operation. Seven cases showed bleeding from the cut surface of the muscle. Other bleeding points included vessels and the Berry ligament. There were no additional complications after reoperation. Conclusion: When separating the muscles in neck surgery, it is important to sufficiently ligate vessels and induce coagulation with an ultrasonically activated scalpel to prevent postoperative bleeding.

Cause analysis and reoperation effect of failure and recurrence after epiblepharon correction in children

BACKGROUND In children, it is common to see failure and recurrence in the correction ofepiblepharon and to have reoperation due to obvious irritation symptoms andcorneal injury.AIM To explore the causes of failure and recurrence after epiblepharon correction inchildren, to remove accurately redundant epiblepharon and orbicularis oculimuscle in patients via the cilia-everting suture technique combined with lidmargin splitting in some patients due to inverted lashes in the medial part of theeyelid, and to observe the therapeutic effect.METHODS From 2015 to 2019, in the Outpatient Department of Ophthalmology of BeijingTongren Hospital, 22 children (40 eyes) with epiblepharon, aged 5-12 years, weretreated due to correction failure and recurrence. Fourteen patients (28 eyes)underwent the full-thickness everting suture technique, and eight patients (16eyes) underwent incisional surgery. They were treated by reviewing the previoussurgical methods and observing epiblepharon, eyelash direction, and cornealinjury. During reoperation, a subciliary incision was made 1 mm below theinferior lash line. Incisional surgery for the lower eyelid was used to removeaccurately redundant epiblepharon and part of the pretarsal orbicularis muscle.Subcutaneous tissue and the orbicularis muscle of the upper skin-muscle flapwere anchored to the anterior fascia of the tarsal plate by rotational sutures. Lidmargin splitting was used only for patients who had seriously inverted lasheslocated in the medial part of the eyelid. All patients were followed for 6-12 moafter reoperation to observe the lower eyelid position, skin incision, eyelash direction, corneal damage, and recurrence.RESULTS After reoperation, all the patients were corrected. Photophobia, rubbing the eye,winking, and tearing disappeared. There was no lower eyelid entropion,ectropion, or retraction. There was no obvious sunken scar or lower eyelid crease.The eyelashes were far away from the cornea, and when the patients lookeddown, the eyelashes on the lower eyelid did not contact the cornea or conjunctiva.The corneal injuries were repaired. Follow-up observation for 6 mo showed norecurrence of epiblepharon.CONCLUSION The type of suture method, the failure to remove accurately redundant skin andorbicularis muscle, the lack of cilia rotational suture use, and excessive reversegrowth of eyelashes are the main causes of failure and recurrence afterepiblepharon correction in children.

Clinical online nomogram for predicting prognosis in recurrent hepatolithiasis after biliary surgery:A multicenter,retrospective study

BACKGROUND Methods for predicting the prognosis of patients undergoing surgery for recurrent hepatolithiasis after biliary surgery are currently lacking.AIM To establish a nomogram to predict the prognosis of patients with recurrent hepatolithiasis after biliary surgery.METHODS In this multicenter,retrospective study,data of consecutive patients in four large medical centers who underwent surgery for recurrent hepatolithiasis after biliary surgery were retrospectively analyzed.We constructed a nomogram to predict the prognosis of recurrent hepatolithiasis in a training cohort of 299 patients,following which we independently tested the nomogram in an external validation cohort of 142 patients.Finally,we used the concordance index(C-index),calibration,area under curve,decision curve analysis,clinical impact curves,and visual fit indices to evaluate the accuracy of the nomogram.RESULTS Multiple previous surgeries[2 surgeries:Odds ratio(95%confidence interval),1.451(0.719-2.932);3 surgeries:4.573(2.015-10.378);≥4 surgeries:5.741(1.347-24.470)],bilateral hepatolithiasis[1.965(1.039-3.717)],absence of immediate clearance[2.398(1.304-4.409)],neutrophil-to-lymphocyte ratio≥2.462[1.915(1.099-3.337)],and albumin-to-globulin ratio≤1.5[1.949(1.056-3.595)]were found to be independent factors influencing the prognosis.The nomogram constructed on the basis of these variables showed good reliability in the training(C-index:0.748)and validation(C-index:0.743)cohorts.Compared with predictions using traditional classification models,those using our nomogram showed better agreement with actual observations in the calibration curve for the probability of endpoints and the receiver operating characteristic curve.Dichloroacetate and clinical impact curves showed a larger net benefit of the nomogram.CONCLUSION The nomogram developed in this study demonstrated superior performance and discriminative power compared to the three traditional classifications.It is easy to use,highly accurate,and shows excellent calibration.