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.

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.

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.

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.

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.

Promising short-term clinical results of the cementless Oxford phase Ⅲ medial unicondylar knee prosthesis

AIM: To investigate the short-term clinical results of the Oxford phase III cementless medial unicondylar knee prosthesis(UKP) compared to the cemented medial UKP.METHODS: We conducted a cross-sectional study in a tertairy orthopedic centre between the period of May 2010 and September 2012. We included 99 medial UKP in 97 patients and of these UKP, 53 were cemented and 46 were cementless. Clinical outcome was measured using a questionnaire, containing a visual analogue scale(VAS) for pain, Oxford Knee score, Kujala score and SF-12 score. Knee function was tested using the American Knee Society score. Complications, reoperations and revisions were recorded. Statistical significance was defined as a P value < 0.05.RESULTS: In a mean follow-up time of 19.5 mo, three cemented medial UKP were revised to a total knee prosthesis. Reasons for revision were malrotation of the tibial component, aseptic loosening of the tibial component and progression of osteoarthritis in the lateral- and patellofemoral compartment. In five patients a successful reoperation was performed, because of impingement or(sub)luxation of the polyethylene bearing. Patients with a reoperation were significant younger than patients in the primary group(56.7 vs 64.0, P = 0.01) and were more likely to be male(85.7% vs 38.8%, P = 0.015). Overall the cementless medial UKP seems to perform better, but the differences in clinical outcome are not significant; a VAS pain score of 7.4 vs 11.7(P = 0.22), an Oxford Knee score of 43.3 vs 41.7(P = 0.27) and a Kujala score of 79.6 vs 78.0(P = 0.63). The American Knee Society scores were slightly better in the cementless group with 94.5 vs 90.2(P = 0.055) for the objective score and 91.2 vs 87.8(P = 0.25) for the subjective score.CONCLUSION: The cementless Oxford phase III medial UKP shows good short-term clinical results, when used in a specialist clinic by an experienced surgeon.

Is there any difference in anesthetic management of different post-OLT stage patients undergoing nontransplant organ surgery?

BACKGROUND: Little information is available about anesthesia management of nontransplant organ surgery of recipients after adult liver transplantation. The aim of this study was to discuss the anesthesia management of recipients for different stages after liver transplantation. METHODS: The medical records of 16 patients were reviewed after OLT scheduled for elective nontransplant organ surgery at our institution from September 2002 to October 2005. The patients were divided into perioperative stage (group A) and mid-term and long-term stage (group B) groups according to post-OLT time. The data of 16 patients preoperation, intraoperation and postoperation were analyzed. RESULTS: The measurements of alanine transaminase (ALT), total bilirubin (TB), prothrombin time (PT), and lung infection were significantly higher in group A than in group B (P<0.05). The incidence of hyperglycaemia was significantly higher in group B than in group A (P<0.05). During operation the incidence of hypotension was significantly higher in group A than in group B (P<0.05). After operation, the number of patients in ICU was significantly larger and the extubation time was longer in group A than in group B. General anesthesia was induced in 14 patients, and regional anesthesia in 2 patients. CONCLUSIONS: Regional or general anesthesia can be safely delivered to adult OLT recipients except for contraindications. Special considerations include protection of the function of important organs, correction of hemodynamic instability in perioperative stage patients after OLT, and measurement of the side-effects of immunosuppression in mid-term and long-term stage patients.

Clinical outcomes after intrastromal corneal ring segments reoperation in keratoconus patients

AIM:To evaluate the clinical outcomes after Ferrara intrastromal corneal ring segments(ICRS)reoperation in patients with keratoconus.METHODS:A total of 37 keratoconus eyes implanted with intrastromal corneal ring segments,which had an ICRS exchange,addition,reposition or removal were evaluated.Uncorrected visual acuity(UCVA),best corrected visual acuity(BCVA),keratometry(K),asphericity(Q)and pachymetry at the thinnest point(PTP)of the cornea were evaluated using a corneal tomography(Oculus Pentacam,USA)RESULTS:The mean follow-up time after the reoperation was 30.5±9.7 months.The mean UCVA improved from 20/300 to 20/80(P=0.005);the mean BCVA improved from 20/160 to 20/50(P=0.0002),the mean keratometry reduced from 49.33±4.19D to 46.16±3.90D(P=0.0001),the mean pachymetry at the thinnest point increased from 450±42.9μm to 469±40.8μm(P=0.0001).The asphericity increased from-0.84±0.74 to-0.35±0.81(P=0.15)and the spherical equivalent reduced from-4.64±4.87D to-3.04±3.45D(P=0.137).The changes in the asphericity and spherical equivalent were not statistically significant.CONCLUSION:Ferrara ICRS implantation showed to be a reversible and readjustable surgical procedure for keratoconus treatment.Good outcomes can be obtained even after removal,addition,reposition or exchange of ICRS.

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

BACKGROUND The national rates of readmission and reoperation after open reduction internal fixation(ORIF)of midshaft clavicle fractures in adolescents is unknown.AIM To determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.METHODS This retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012.Readmissions within ninety days,reoperations within two years,and differences in patient demographic factors were determined through descriptive,univariate,and multivariate analyses.RESULTS In total,3.29%(n=11)of patients were readmitted within 90 d to a hospital at an average of 18.91±18 d after discharge,while 15.87%(n=53)of patients underwent a reoperation within two years at an average of 209.53±151 d since the index surgery.The most common reason for readmission was a postoperative infection(n<10).Reasons for reoperation included implant removal(n=49)at an average time of 202.39±138 d after surgery,and revision ORIF(n<10)with an average time of 297±289 d after index surgery.The odds of reoperation were higher for females(P<0.01)and outpatients(P<0.01),while the odds of reoperation were lower for patients who underwent surgery in California(P=0.02).CONCLUSION There is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents.There are significant differences for reoperation based on patient sex,location,and hospital type.

Clinical Predictors for Recurrence after Curative Resection for Colorectal Cancer

Purpose: To identify clinical predictors of recurrence of colorectal cancer after curative surgical treatment. Methods: Retrospective follow-up-study of 925 consecutive patients treated with R0-resection for colorectal cancer Stage I, II and III from 1990 until 2000 with a mean follow-up of 60 ± 37 months. Predictors for cancer recurrence were identified in a pilot-sample of these patients, followed by analyses of the rest of the patients (test-sample), and finally with a concluding analyses of the entire patient group. Data were analyzed with Pearson Chi-square test (χ2), Cox regression analyses and log rank test. Results: Tumor stage (Stage I: HR 0.10 (0.05;0.19), Stage II: HR 0.31 (0.24;0.41)) and postoperative reoperations due to complications due to other causes than anastomotic leakage (HR 2.02 (1.21;3.36)) were significant predictors of cancer recurrence in the multivariate Cox regression model. The association between reoperations and recurrence was strongest for the patients with the best prognosis: Stage I and Stage II-cancers. Long duration of surgery, strongly associated with blood-loss and infusions of liquid and blood-products, reoperation due to anastomotic leakage as well as right colon/transversum localization were significant at a trend-level (10%). Conclusions: Tumor stage and reoperations due to postoperative complications other than anastomotic leakage are significant predictors for recurrence after curative surgery for colorectal cancer.