The use of lyophilized bovine pericardium (Tutopatch®) in the management of third nerve palsy following prior conventional strabismus surgery - a case series.

To study the secondary management of strabismus due to third nerve palsy using bovine pericardium (Tutopatch®) when previous conventional surgical therapy had failed. Review of our clinic records of selected patients with third nerve palsy, in whom residual deviation had been managed using Tutopatch® after previous surgical correction. The squint angle was measured preoperatively, and at 1 day, 3 months, and if possible 6 months postoperatively. Nine patients were enrolled in this study. One patient had mainly residual vertical deviation and was corrected with tendon elongation of the contralateral superior rectus. Three patients were operated on with tendon elongation of the lateral rectus muscle with or without medial rectus muscle resection and/or advancement (Group 1). Lateral rectus splitting after tendon elongation in addition to the resection and/or advancement of the medial rectus was performed in five patients with complete third nerve palsy (Group 2). In Group 1, the preoperative median squint angle was -20° (range -17° to -25°), which improved postoperatively to -4.5° (range -12° to +3°). In Group 2, the preoperative horizontal and vertical median squint angles were -27° (range -20° to -40°) and 0.5° (range 0° and 20°), respectively. Postoperatively, they had improved to -12.5° (range-2° to -25°), and 1.5° (range 0° to 7°), respectively. Two patients of Group 2 were re-operated due to residual exotropia. No postoperative complications were observed in any patient. In this small series several complex re-do situations of patients with third nerve palsy were evaluated in which Tutopatch® markedly improved outcomes after an initially ineffective surgical management. For better evaluation of its usefulness a study with more patients is recommended.

Rates and risk factors associated with 30- and 90-day readmissions and reoperations after spinal fusions for adult lumbar degenerative pathology and spinal deformity.

PURPOSE: Analyze state databases to determine variables associated with of short-term readmissions and reoperations following thoracolumbar spine fusions for degenerative pathology and spinal deformity. METHODS: Retrospective study of State Inpatient Database (2005-13, CA, NE, NY, FL, NC, UT). INCLUSION CRITERIA: age > 45 years, diagnosis of degenerative spinal deformity, ≥ 3 level posterolateral lumbar spine fusion. EXCLUSION CRITERIA: revision surgery, cervical fusions, trauma, and cancer. Univariate and step-wise multivariate logistic regression analyses were performed to identify independent variables associated with of 30- and 90-day readmissions and reoperations. RESULTS: 12,641 patients were included. All-cause 30- and 90-day readmission rates were 14.6% and 21.1%, respectively. 90-day readmissions were associated with: age > 80 (OR: 1.42), 8 + level fusions (OR: 1.19), hospital length of stay (LOS) > 7 days (OR: 1.43), obesity (OR: 1.29), morbid obesity (OR: 1.66), academic hospital (OR: 1.13), cancer history (OR:1.21), drug abuse (OR: 1.31), increased Charlson Comorbidity index (OR: 1.12), and depression (OR: 1.20). Private insurance (OR: 0.64) and lumbar-only fusions (OR: 0.87) were not associated with 90-day readmissions. All-cause 30- and 90-day reoperation rates were 1.8% and 4.2%, respectively. Variables associated with 90-day reoperations were 8 + level fusions (OR: 1.28), LOS > 7 days (OR: 1.43), drug abuse (OR: 1.68), osteoporosis (OR: 1.26), and depression (OR: 1.23). Circumferential fusion (OR: 0.58) and lumbar-only fusions (OR: 0.68) were not associated with 90-day reoperations. CONCLUSIONS: 30- and 90-day readmission and reoperation rates in thoracolumbar fusions for adult degenerative pathology and spinal deformity may have been underreported in previously published smaller studies. Identification of modifiable risk factors is important for improving quality of care through preoperative optimization.

Clinical Outcomes Following Re-Operations for Intracranial Meningioma.

The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1-4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8-366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9-41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1-86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

Non-operative predictors for subsequent interventions after intracapsular femoral neck fractures in elderly: A comprehensive analysis of the Hungarian nationwide health insurance database.

OBJECTIVES: To investigate the correlation between non-operative prognostic factors and non-prosthetic fracture-related treatments following internal fixation of intracapsular femoral neck fractures in elderly patients. DESIGN AND SETTING: Retrospective observational cohort study. Comprehensive analysis of the Hungarian nationwide health insurance database. PARTICIPANTS: Data of in-patient records with S7200 ICD-10 codes were collected from the Hungarian National Health Insurance Fund Administration (HNHIFA) and from the health care provider institutes. The patients with femoral neck fractures in the year of 2000, following reduction and internal fixation aged 60 years or older were evaluated. The secondary, non-prosthetic fracture related treatments during the 8 year follow-up period were registered. MAIN OUTCOME MEASURES: Of the prognostic factors, age, gender, type of fracture, season and day of the primary surgery, length of waiting time to the operation and the accompanied diseases were evaluated as risk factors for all type of fracture-related further interventions, with the exception of arthroplasties. RESULTS: A total of 2895 patients with intracapsular femoral neck fractures met the study criteria. The mean age was 77.96 years (SD: 8.54). The cohort of the patients was observed for a total of 10,077.8 person-years. The non-prosthetic fracture related treatment was performed in 265 patients (9,2%); the median of the time elapsed to the secondary definitive treatment was 3.5 months. With Cox regression analysis, significant correlation was revealed between the incidence of non-prosthetic treatment and younger age (year, HR = 0.977, p = 0.002), surgical delay (12-24 h vs 0-6 h, HR = 1.518, p = 0.023; 24h+ vs 0-6 h, HR = 1.372, p = 0.050), season of primary osteosynthesis (fall vs summer, HR = 0.636, p = 0.012), and type of femoral neck fracture (intracapsular displaced vs intracapsular undisplaced, HR = 1.340, p = 0,047). There was no significant effect of the day of primary surgery, the gender and the presence of co-morbidities on the incidence of further surgical interventions. CONCLUSION: The summertime primary surgical intervention, delay of surgery longer than 12 h and type of femoral neck fracture are independent predictors of non-prosthetic further treatment of femoral neck fractures in elderly patients. LEVEL OF EVIDENCE: Level IV, evidence from cohort studies.

Complications and re-operations after tension-free vaginal tape operation in women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: We evaluate intraoperative and short-term postoperative (≤ 3 months) complications and long-term re-operations (up to 6 years) after tension-free vaginal tape (TVT) operation in women with stress urinary incontinence (SUI). METHODS: Data from 446 women undergoing TVT operation between 2012 and 2016 at a tertiary referral center was retrospectively collected. Data included patient baseline demographics, information from the TVT operation and the following postoperative period, and scores from patient questionnaires [the International Consultation of Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and Patient Global Impression of Improvement (PGI-I)]. Collected data were investigated for incidence of complications and re-operations, postoperative improvement in patient questionnaires, and association between complications and baseline patient demographics. RESULTS: The only intraoperative complication was bladder perforation (2.0%). Postoperative complications included: infection (0.7%), hematoma (0.9%), bleeding (0.2%), pain (0.9%), erosion of the vaginal mucosa (1.1%), persistent SUI (0.7%), and voiding dysfunction > 24 h (10.3%). Re-operations included: operation due to infections (0.4%), incontinence surgery for persistent SUI (0.4%), revision for tape erosion (1.1%), tape mobilization (3.6%), and tape division (0.2%). A significant reduction in urinary incontinence symptoms was observed in the ICIQ-UI SF and PGI-I. The reduction in ICIQ-UI SF did not vary significantly between patients with and without complications. No association between complications and baseline patient demographics was found. CONCLUSION: This study demonstrated high safety and efficacy of the TVT operation with only minor short-term complications and few long-term re-operations. The ICIQ-UI SF improved significantly postoperatively and was not statistically significantly affected by the occurrence of complications.

Analysis of re-operations after cervical total disc replacement in a consecutive series of 535 patients receiving the ProDisc-C device.

INTRODUCTION: One important factor in evaluating the safety of an implant is the rate of subsequent surgery and the reasons for surgery, particularly those that are related to possible problems with the implant. The purpose of this study was to determine the overall re-operation rate (including revisions, removals, device-related, procedure-related, adjacent segment, and others) for a large consecutive series of cervical TDR patients beginning with the first case experience, using a single device at a single institution. METHODS: Surgery records were reviewed to identify cervical TDR patients and those who underwent subsequent surgery. Cervical TDR cases involving ProDisc-C were identified, beginning with the first case performed in 2003 at a multisite spine specialty centre. Only patients who were at least 2 years post-operative were included, producing a consecutive series of 535 patients. There were 115 hybrids in the series (TDR at one level and fusion at an adjacent segment). Data collected included general demographics and level(s) operated. A surgery log through 12-31-18 was reviewed to identify re-operations occurring in the TDR patients. For each re-operation, the reason, duration from index surgery, and procedure were recorded. The mean duration from the index surgery to the search of the surgery log for re-operations was 78.3 months, range 24 to 181 months. RESULTS: Re-operation occurred in 30 patients (5.6%). These included: 3 TDR removals and revision to anterior discectomy and fusion (1 for migration, 1 for subsidence, and 1 for spondylosis), 1 TDR repositioning, 21 secondary surgeries for adjacent segment degeneration (5 of which were adjacent to fusion levels in hybrid procedures), 1 wound infection, 1 hematoma, and 2 received stimulators for pain control. There were no re- operations for device failure. In cases of re-operation for adjacent segment degeneration, the mean duration between the index surgery and re-operation was 47.3 months. CONCLUSION: The re-operation rate was 5.6%. No surgeries were performed for device failure. These results support the safety of the TDR device.

Characteristics of groin hernia repair in patients without a groin hernia: a nationwide cohort study.

BACKGROUND: Sports hernia is a condition with longstanding groin pain without an obvious pathology. Even though no hernia is present, some of these patients have a groin hernia repair to relieve the pain. The aim of this study was to establish an overview of patient characteristics and surgical techniques in patients that have a groin hernia repair without a hernia present. METHODS: This cohort study is based on nationwide data on hernia repairs from the Danish Hernia Database. Patients having a primary groin hernia repair without having a hernia between 1998 and 2011 were included and followed for minimum 4 years. We evaluated patient characteristics, type of surgery, and re-operation rates for laparoscopic and open surgeries. RESULTS: Groin hernia repairs were performed in 1,028 groins where no hernia was present. The median follow-up after primary surgery was 11 years (range 4-17). Men represented 78% of the patients, and the mean age was 50 years (standard deviation 16.4). The most frequent type of surgery was the open Lichtenstein repair. The overall re-operation rate was 7% and this was evenly distributed across the different types of primary surgeries with no difference in neither the crude nor the cumulated re-operation rates. During re-operation, a groin hernia was found in 88% of the repairs. CONCLUSION: Groin hernia repairs in groins without a hernia are performed at all ages and with the typical patient being a middle-aged man receiving an open mesh repair.

Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications.

OBJECTIVE: The primary aim was to evaluate the number of complications following locking plate fixation of proximal humeral fractures in country X and in country Y. The secondary aim was to identify risk factors for complications. METHODS: Multicentre retrospective case series of 282 consecutive patients with proximal humeral fractures, treated with a locking plate between 2010 and 2014. SETTING: two level 1 trauma centres in country X and one in country Y. Data pertaining to demographics, postoperative complications and re-operations were collected. Fractures were classified according to the AO and Hertel classifications and experienced surgeons assessed the quality of reduction and plate fixation on the postoperative X-rays. Outcomes of the two different countries were compared and logistic regression analysis was performed to analyse the relationship between risk factors and complications. RESULTS: During a median follow-up of 370 days, 196 complications were encountered in 127 patients (45%). The most frequent complications were: screw perforation in the glenohumeral joint (23%), persistent shoulder complaints (16%), avascular necrosis of the humeral head (10%) and secondary fracture displacement (5%). In 80 patients (28%), 132 re-operations were performed. The patients operated in country X had significantly more complications compared with the patients operated in country Y. For implant-related complications, advanced age, non-anatomic reduction of the greater tuberosity, and country of operation were risk factors. CONCLUSION: The use of locking plates for proximal humeral fractures was associated with a high number of complications in both countries; the patients operated in country Y, however, had better results compared with the patients operated in country X. LEVEL OF EVIDENCE: IV.

Survival of the Scandinavian total ankle replacement (STAR): results of ten to nineteen years follow-up.

PURPOSE: The purpose of this study was to evaluate survival and clinical outcome of the Scandinavian total ankle replacement (STAR) prosthesis after a minimum of ten years up to a maximum of 19 years. METHODS: Fifty STAR prostheses in 46 patients with end stage ankle osteoarthritis operated between 1996 and 2006 by the same surgeon (MH) were included. Minimal follow-up was ten years (median 14.6 years, 95% confidence interval [CI] 12.9-16.4). Clinical (Kofoed score) and radiological assessments were taken before the operation and at one, ten (+2), and 16 (±3) years after implantation. The primary endpoint was defined as exchange of the whole prosthesis or conversion to arthrodesis (def. 1), exchange of at least one metallic component (def. 2), or exchange of any component including the inlay (due to breakage or wear) (def. 3). Survival was estimated according to Kaplan-Meier. Further reoperations related to STAR were also recorded. RESULTS: The ten year survival rate was (def. 1) 94% (CI 82-98%), (def. 2) 90% (CI, 77-96%), and (def. 3) 78% (CI 64-87%). The 19-year survival rate was (def. 1) 91% (CI 78-97%), (def. 2) 75% (CI 53-88%), and (def. 3) 55% (CI 34-71%). Considering any re-operations related to STAR, 52% (26/50) of prostheses were affected by re-operations. Mean pre-operative Kofoed score was 49, which improved to 84 after one year (n = 50), to 90 after ten years (n = 46), and to 89 after 16 years (n = 28). CONCLUSIONS: The survival rate for def. 1 and 2 was high. However, re-operations occurred in 52% of all STAR prosthesis. STUDY DESIGN: Retrospective cohort study, evidence Level 4.

Prevalence and risk factors for re-interventions following reamed intramedullary tibia nailing.

INTRODUCTION: This study aimed to identify the prevalence and the risk factors for re-interventions following reamed intramedullary nailing (IMN) of tibial shaft fractures. PATIENTS AND METHODS: We retrospectively analysed a prospectively populated data of adult patients that underwent reamed intramedullary nailing for stabilization of tibial shaft fractures over a period of three years. Exclusion criteria were immature patients, pathological and periarticular fractures. Data collected included patient demographics, mechanism of injury, open or closed injury pattern, ISS, perioperative complications, reintervention characteristics (time, cause, number), smoking habits, medical co-morbidities and progress to radiological fracture union. Fractures were classified according to AO/OTA system. The cohort of these patients was divided in two groups: Group 1 included the patients who healed uneventfully and Group 2 included the patients who underwent a re-intervention for the healing of the fracture. A logistic regression analysis model was used to assess the odds ratio (OR) of identified risk factors predicting the necessity of re-interventions. RESULTS: 181 (129 male) patients with a mean age of 37 (range 16-87) met the inclusion criteria. 30 patients were excluded due to inadequate follow up, leaving 151 patients for the study group. 119 patients were included in Group 1. 32 (21.2%) patients who had at least one re-intervention (range 1-3) were included in Group 2. The most common causes for re-intervention were aseptic non-union (31.3%) and removal of implants due to soft tissue irritation/anterior knee pain (31.3%), followed by early metalwork failure (12.5%), infected non-union (9.4%), correction of rotational deformities (9.4%) and canal intramedullary sepsis with evident fracture healing (6.3%). 29 (25.8%) from the study cohort patients sustained an open fracture and 8 of them underwent a re-intervention (20.5% of interventions). Incidence of fracture pattern 42-B, C was statistically significant greater in the reintervention (40.6%) compared to the non-re-intervention group (23.53%) (p = 0.026). Risk factors predicting the need for re-interventions included the type of fracture B, C (p = 0.026 OR: 2.528, range: 1.117-5.721) and increased alcohol consumption (p = 0.027/OR: 2.618, range: 1.116-6.141). CONCLUSION: Fracture pattern and alcohol abuse were highly predictive for re-interventions following reamed IM nailing for stabilization of acute tibial shaft fractures.

[Impact of transcatheter aortic valve implantation in the treatment of aortic valve disease after previous coronary artery bypass]. / Impact des techniques interventionnelles dans le traitement de la valvulopathie aortique après revascularisation myocardique chirurgicale préalable.

INTRODUCTION: Patients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization. PATIENTS AND METHODS: This is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013. RESULTS: The introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment. CONCLUSION: Surgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.

Laparoscopic Roux-en-Y gastric bypass patients have an increased lifetime risk of repeat operations when compared to laparoscopic sleeve gastrectomy patients.

BACKGROUND: Although long-term data have been published on the complications after laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) is a relatively new procedure without a well-established long-term procedure-related morbidity profile. Our aim was to compare the 6-year data on re-operations occurring after and related to LRYGB versus LSG at a large academic bariatric center. METHODS: Retrospective review of all the bariatric procedures at the Massachusetts General Hospital between 2009 and 2014. RESULTS: A total of 934 LRYGB and 553 LSG were performed. There were no significant differences in the gender, age, or BMI of the patients at the time of their index operations (p > 0.05 for all). A higher percentage of LRYGB patients required cholecystectomy as compared to LSG patients (5 vs. 2 %, X (2) = 8.63, p < 0.01). There was also a significant difference in the proportion of patients requiring re-operations for other reasons following LRYGB as compared to LSG (6.9 vs. 0.9 %, X (2) = 27.8, p < 0.01). A total of 32.8 % of these bypass patients underwent more than one re-operation, with a relative risk of 11.5 (95 % CI 4.69-28.5) as compared to those undergoing SG. A total of 9.3 % of secondary operations occurred at a mean of 1 month after the LRYGB for functional obstruction, with most of these cases related to a technical error. Other re-operations occurred in a delayed fashion, without a clearly identifiable intra-abdominal source in 22.2 %, due to adhesive bowel obstruction in 17.6 %, and internal hernia in 15.7 %. Non-healing ulcers and intussusception were responsible for a small percentage of re-operations (3.7 and 2.8 %). CONCLUSIONS: SG is associated with a relatively low rate of re-operations, while patients after LRYGB are at a significant long-term risk for multiple operative procedures.

Factores predictivos de reintervención en cirugía colorrectal laparoscópica / Predictive factors for reoperation after colorrectal laparoscopic surgery

Introducción: son varios los criterios que se han propuesto para determinar los factores predictivos de complicaciones en cirugía colorrectal laparoscópica. Objetivo: identificar los posibles factores predictores de reintervención después de cirugía colorrectal laparoscópica. Métodos: se revisaron las historias clínicas de los pacientes reintervenidos por complicaciones después de cirugía colorrectal laparoscópica en el Centro Nacional de Cirugía de Mínimo Acceso (CNCMA), en el período comprendido de enero de 2007 a diciembre de 2011. A través de un modelo de regresión logística, se estudió la asociación entre la reintervención y las siguientes variables independientes: edad, sexo, enfermedad de base (indicación quirúrgica), tiempo quirúrgico, tipo de anastomosis, tipo de sutura mecánica. Se consideró estadísticamente significativo un valor p < 0,05. Resultados: se reintervinieron 27 pacientes de 330 operados. La técnica quirúrgica (Dixon bajo) y el tipo de anastomosis (extracorpórea) fueron las variables que se asociaron de manera estadísticamente significativa con la presencia de reintervención en la cirugía colorrectal. Conclusiones: la técnica quirúrgica (Dixon bajo) y el tipo de anastomosis (extracorpórea) son posibles factores predictivos de reintervención en los operados de enfermedades colorrectales por vía laparoscópica(AU)

Introduction: numerous criteria have been stated in order to determine predictive factor for laparoscopic colorectal surgery. Objective: to identify possible predictive factors for reoperation after laparoscopic colorectal surgery. Methods: the medical records of re-operated patients due to complications after laparoscopic colorectal surgery at the National Center of Minimal Access Surgery were checked from January 2007 to December 2011. A logistic regression model allowed analyzing the association between reoperation and the following independent variables: age, gender, underlying disease (surgery indications), surgical time, type of anastomosis, type of mechanical suture. The statistically significant value of p< 0.05 was taken. Results:twenty seven out of 330 patients with laparoscopic colorectal surgery were re-operated. The surgical procedure (low Dixon) and type of anastomosis (extracorporeal) showed statistically significant association with reoperation after laparoscopic colorectal surgery. Conclusions: the surgical procedure (low Dixon) and type of anastomosis (extracorporeal) were possible predictive factors for re-operation after laparoscopic colorectal surgery(AU)

Ninety-day morbidity in patients undergoing primary TKA with discontinuation of warfarin and bridging with LMWH.

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

Two Successful Proximal Reoperation Cases after Acute Type A Dissection Repair / 日本心臓血管外科学会雑誌

We report 2 cases of successful proximal reoperations after acute type A dissection. Case 1 : A 53-year-old man underwent ascending aorta and aortic arch replacement and aortic valve re-suspension for acute type A dissection with aortic valve regurgitation in 1992. Thirteen years after the first operation, computed tomography demonstrated a Valsalva aneurysm (74 mm) and Doppler echocardiography showed moderate aortic valve regurgitation. Therefore, we performed an operation. We could not locate the dissection in the Valsalva sinus, and the aortic valve cusps had organic change. A David procedure was performed. The postoperative course was uneventful and he was discharged on the 19th postoperative day. Case 2 : A 65-year-old woman underwent ascending aorta replacement and aortic valve resuspension for acute type A dissection with aortic valve regurgitation in 1997, but 11 years after the first operation, computed tomography demonstrated a Valsalva aneurysm (55 mm) and arch aneurysm (65 mm) with stenosis of the innominate vein and she had facial and left arm edema. Doppler echocardiography showed moderate aortic valve regurgitation. We could not find the location of dissection in the Valsalva sinus or aortic arch, and aortic valve cusps had no organic change. A Bentall procedure and total arch replacement were performed and her postoperative course was uneventful.

Surveillance & management of out-of-plan re-operations / 中华医院管理杂志

A series of surveillance and management actions was taken to minimize out-of-plan re-operations. These actions include: 1) Building and completing the surveillance and management mechanism against unplanned re-operations; 2) Building a real-time surveillance and reporting mechanism; 3) Enhancing quality control and continuous improvement at the operating departments; 4) Enhancing the supervision on regulations implementation by quality control departments of the hospital; 5) Enhancing quality control for medical records; 6) Building a feedback mechanism for surveillance results; 7) Building a penalty and reward mechanism. Efforts for one year and a half on such surveillance and management proved successful, as the incidence of out-of-plan re-operations fell from 1.7% before these actions to 1.0% afterwards.