Aggressive Surgical Treatment Research Articles

Rapid sequential development and rupture of mycotic aneurysms within a period of days in a patient with graft-versus-host disease and angiotropic Scedosporium apiospermum infection

Background: Fungal origin mycotic aneurysms are rare and carry a high mortality rate. Scedosporium apiospermum is an ubiquitous fungus which has been described to cause devastating infections in immunocompromised hosts.Case Description: We report a case of a 23-year-old patient with Burkitt’s lymphoma and graft-versus-host disease admitted with intracerebral hemorrhage and sequential development of 12 anterior circulation aneurysms from disseminated Scedosporium infection. Despite aggressive surgical and antimicrobial treatment, the patient died 6 months later from multiorgan failure. The notable feature of this case is the rapid angioinvasiveness of the infection with new aneurysm formation within days of clear angiographic imaging despite the apparent lack of skull base osteomyelitis.Conclusion: We highlight the difficulties in treating fungal mycotic aneurysms and the associated high mortality. While a less aggressive approach might have been appropriate given the known poor outcomes, the age of the patients as well as the family wishes dictated the treatment decisions.

Racial Disparities in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Aggressive Surgical Treatment Overcome Cancer Health Inequities?

BackgroundAdvanced cancer states perpetuate health-related disparities. Peritoneal-based cancers are clinically advanced cancers that present a significant clinical dilemma. Peritoneal cancers are managed aggressively with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). While racial and ethnic disparities are prevalent in cancer, there are no studies investigating if racial disparities exist in patients with peritoneal carcinomatosis managed with CRS and HIPEC. We hypothesized that this advanced disease state further delineates racial disparities.MethodsA retrospective chart review was conducted on patients with peritoneal carcinomatosis receiving CRS and HIPEC at a single institution from January 1, 2017-October 4, 2021. Descriptive statistics were used to compare racial groups. The Cox Proportional Hazards Model and Log Rank Test were used for multivariate and overall survival analysis.ResultsIn total, 67 patients underwent CRS and HIPEC, of which 41 (61.2%) were White, 20 (29.8%) were Black, 3 (4.5%) were Asian, and 3 (4.5%) were Other race. When compared to White patients, Black patients had lower income (p=0.0011), higher incidence of hypertension (p=0.0231), and lower performance status (p=0.0441). Cancer type, including colorectal, appendiceal, ovarian, etc., was similar between groups (p=0.8703). Despite these differences in sociodemographic and morbidity factors, when comparing Black patients to White patients, there were no differences in peritoneal cancer index score (13.2 vs. 12.3, p=0.6932), estimated blood loss (748 vs. 655 mL, p=0.6332), minor/major complication rates (1.1 vs. 1.2, p=0.7281; 0.4 vs. 0.7, p=0.3470, respectively), 30-day readmission rates (25.0% vs. 17.1%, p=0.6210), disease recurrence (40.0% vs. 51.2%, p=0.3667), or 30-day mortality (0.0% vs. 2.4%, p=1.0000). Overall survival was similar for Black and White patients (p=0.2693). The occurrence of a major complication was the only factor associated with overall survival (HR 2.188 [1.502, 3.188], p< 0.0001).ConclusionsDespite differences in patient socioeconomic factors and comorbid conditions, outcomes were similar between Black and White patients receiving CRS and HIPEC at our institution. While larger studies with more diverse patient populations are needed to confirm these findings, our data provide evidence that aggressive surgical management across diverse patient populations allows for equitable outcomes.

Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage

Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associatedwith unfavorable outcomes (odds ratio [OR], 9.54, P= 0.03; OR, 5.37, P= 0.04; OR, 11.80, P= 0.009; OR, 0.14, P= 0.02 and OR, 6.53, P= 0.04, respectively). The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.

CLINICAL PROFILE OF MUCORMYCOSIS IN TERTIARY CARE CENTER IN NORTHERN INDIA

Purpose: The objective of the study is to study the clinical prole of Mucormycosis in tertiary care center in Northern India. Materials And Methods: This was prospective study which analyzed patients with rhino-orbital mucormycosis, referred to our department from May 2021 to August 2021.After taking a detailed ocular and systemic history, each patient underwent a complete eye examination. Diagnosis was based on nasal swab KOH mount and fungal culture and was conrmed on MRI brain, orbit and PNS in all patients. The characteristics studied were demographic details, clinical features, predisposing factors and co-morbid illnesses. The treatment in terms of usage of antifungal (amphotericin B and posaconazole), antibiotics and surgery was also noted. Statistical Methods: Descriptive analyses were used to study the parameters. Results: A total of 138 patients of mucormycosis were referred to our department. Seventy patients were male and sixty eight patients were female. Uncontrolled diabetes mellitus was the most common underlying predisposing factor. Patients presented with wide range of symptoms of which visual disturbance was the most common symptom. 35 (25.3%) patients were treated with conventional Inj Amphotericin-B and 26 (18.8%) patients were treated with oral antifungal drug due to complications such as hypotension, elevated urea/ creatinine levels. 31 patients underwent surgical debridement of the eschar within the nose/ paranasal sinuses. 8 patients underwent orbital exenteration of the involved orbit for complete clearance of disease and to limit the spread of infection intracranially. Conclusion: Early diagnosis with pathological conrmation and aggressive surgical treatment gives a better outcome.

P-295 Prognostic impact of clinico-pathologic parameters in early- and average-onset curatively resected colorectal cancer

Nearly a third of patients with curatively resected colorectal cancer experience recurrence. However, prognostic data do not discern sporadic early onset colorectal cancer (EO-CC) from average onset colorectal cancer (AO-CC). The aim of this study was to estimate the incidence and relevance of routinely assessed clinico-pathologic prognostic parameters across age cohorts. We compared a comprehensive array of clinico-pathologic characteristics in patients with non-metastatic EO-CC (age 60) treated in a tertiary cancer center between 2000-2020, using Fisher’s Exact Test. Logistic regressions and Kaplan Meier curves were performed to determine correlations with patient outcomes. A total of 216 patients with surgically resected non-metastatic primary colon adenocarcinoma met criteria for inclusion in the study (EO-CC: n=73, mean age 42 years, 44.4% male gender; AO-CC: n=143, mean age 71 years, 52.5% male gender). Compared with AO-CC, the EO-CC group was more likely to have family history of cancer (52.4% vs 28.4%, p=0.002), present with tumor obstruction (58.7% vs 24.8%, p 20 nodes removed, 71.4% vs 40.4%, p < 0.001; adjuvant chemotherapy stage 2: 54.3% vs 22.9%, p=0.003, stage 3: 95.2% vs 75%, p=0.08). Overall survival was longer in EO-CC (87.3% vs 78.4% log-rank p=0.001) as expected, however cancer-specific outcomes were significantly inferior for EO-CC with a shorter relapse-free survival (76% vs 86%, log-rank p=0.002) and 1.6 shorter time to recurrence during the designated study period. In both groups, 10% of patients died of cancer. In the EO-CC group, all deaths were cancer-related, most due to active disease and one of capecitabine toxicity, while in AO-CC, 47% of all deaths were cancer related. Recurrence and survival were equally associated with prognostic factors across age cohorts. The prognostic impact of clinico-pathologic parameters were confirmed among EO-CC and AO-CC patients. However, EO-CC had significantly inferior cancer-specific outcomes despite exhibiting identical histopathological features and receiving more aggressive surgical and oncological treatment. Further research should aim to elucidate the causes and manifestations of a potentially more aggressive disease biology.

Idiopathic Granulomatous Mastitis; Radio-pathologic findings and Grading based on Clinical Presentation and treatment outcome in 224 patients

Background: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory disease of the breast with unknown etiology. Clinico-radiologic findings can mimic breast cancer. Further pathologic evaluation to rule out malignancy is mandatory. Recognizing the severity of the disease is crucial to choosing the most effective therapeutic modality. The aim of this study is to evaluate clinical and radio-pathologic features of IGM, and the treatment outcome in a large series of IGM patients in Iran.Methods: The retrospective charts of 243 patients suspicious of IGM, between December 2007 and September 2017 were reviewed. Patients with confirmed diagnosis of IGM were classified into four grades of severity. Demographic information, clinical and radio-pathologic findings, severity and treatment outcomes were collected.Results: Overall, 224 patients were confirmed to have IGM. Breast mass and erythema were the most common clinical findings. Mammographic findings mimicked malignancy in 34%. Lobulo-centric non-caseating granulomas were the most common pathologic finding. Also, 61.5% of the patients had mild to moderate symptoms and 49.5% of them recovered completely by observation. In addition, 53 (25.9%) patients had severe symptoms and 30.8% of them were resistant to treatment. Conclusion: IGM is a diagnostic challenge. Its diagnosis is based on exclusion and a close cooperation between the clinician, the radiologist and the pathologist. Mild to moderate cases can be managed conservatively; however, severe cases may need further aggressive medical or surgical treatments.

Severe skin and soft tissue pythiosis acquired in a hot spring in the southwestern United States, a case report and review of North American cases

BackgroundHuman pythiosis, caused primarily by the aquatic oomycete, Pythium insidiosum, is an emerging but uncommon infection in North America. The infection is frequently life-threatening and is often initially unrecognized due to its rarity and similar presentation to certain fungal infections. MethodsWe report a case of skin and soft tissue pythiosis in a patient without significant underlying comorbidities acquired in a New Mexico hot spring and review its successful treatment. We also review all reported pythiosis cases in North America. ResultsEleven confirmed cases of human pythiosis acquired in North America were identified. The majority of cases occurred in children (64%), ten of eleven cases were acquired in the southern U.S., Mexico, Central America or the Caribbean and four of the eleven individuals succumbed to the infection. ConclusionsWith recognition and aggressive surgical and medical treatment good clinical outcomes can be achieved when treating human pythiosis.

For Patients With Acute PJI Treated With Debridement, Antibiotics, and Implant Retention, What Factors Are Associated With Systemic Sepsis and Recurrent or Persistent Infection in Septic Patients?

Periprosthetic joint infection (PJI) can lead to a severe systemic inflammatory response and may result in systemic sepsis. However, little is known about how often systemic sepsis may occur in patients with PJI, and whether sepsis is associated with a greater likelihood of persistent or recurrent PJI. (1) Among patients who present with acute or acute hematogenous PJI and who were treated with debridement, antibiotics, and implant retention (DAIR), what proportion have sepsis and what factors are associated with a presentation with sepsis? (2) For patients presenting with sepsis, what factors are associated with persistent or recurrent PJI? In all, 320 patients who underwent DAIR for the treatment of acute postoperative or acute hematogenous PJI between January 2000 and December 2019 were included in this study. Exclusion criteria were patients with other known sources of infection, such as pneumonia or urinary tract infections, which could contribute to systemic sepsis (6% [18 of 320]), patients with chronic PJI, and those with less than 6 months of follow-up (21% [66 of 320]). Our final cohort consisted of 236 patients presenting with an acute postoperative or acute hematogenous PJI who underwent an irrigation and debridement procedure. Sepsis was defined by the criteria for systemic inflammatory response syndrome (SIRS) or bacteria-positive blood culture results. Inclusion of patients with positive blood culture by organisms that caused their joint infection was important as all patients presented with fulminant acute infection of a prosthetic joint. Data, including vital signs, surgical variables, and treatment outcomes, were collected retrospectively through a chart review of an electronic medical record system. The statistical analysis comparing patients with sepsis versus patients without sepsis consisted of logistic regression to identify factors associated with sepsis. After confirming its ability to identify patients with a higher association with the development of sepsis through area under the curve models, a nomogram was generated to standardize our results from the regression, which was supported by the area under the curve model, to help readers better identify patients who are more likely to develop sepsis. A total of 44% (103 of 236) of patients had infections that met the criteria for sepsis. After controlling for confounding variables, including congestive heart failure, anemia, serum C-reactive protein (CRP), and the male sex, it was revealed that serum CRP (odds ratio 1.07 [95% confidence interval 1.04 to 1.11]; p < 0.001) and male sex (OR 1.96 [95% CI 1.03 to 3.81]; p = 0.04) were associated with the development of systemic sepsis. For patients presenting with sepsis, persistent or recurrent PJI were associated with an increased CRP level (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.01) and number of prior surgical procedures on the joint (OR 2.30 [95% CI 1.21 to 4.89]; p = 0.02). Overall, our findings support that patients with systematic sepsis may benefit from two-stage revision rather than DAIR to decrease the bioburden more effectively, especially in those with methicillin-resistant Staphylococcus aureus and polymicrobial infections. High serum CRP levels and a history of prior surgical procedures on the involved joint should trigger prompt, aggressive surgical treatment if the patient's overall clinical status can tolerate such an intervention. Level III, therapeutic study.

Role of orbital exenteration in rhino-orbital-cerebral mucormycosis

Purpose–Mucormycosis is an uncommon, rapidly progressive, commonly fatal, opportunistic serious fungal infection.The high mortality rate highlights the importance of early detection and treatment. The purpose of this study to determine theoutcome of orbital exenteration in Rhino-orbital-cerebral mucormycosis(ROCM) patients. Methods and materials–This study includesall proven ROCM patients who had underwent orbital exenteration based on SION Scoring system from 1st may 2021 to 30 june 2021 in MYH hospital, Indore.Those patients were reviewedand the outcome of orbital exenterationwas analysed. Results- Total 29ROCM patients were underwent for orbital exenteration based on SION Scoring system. 19(65.5 %)out of 29 patients had intracranial extension and 10 (34.480%) did not have intracranial extension.&#x0D; Out of 29, 6 (20.68%) patients hadsuccumbed to death within 10 days of orbital exenteration was having bilateral orbital involvement with intracranial extension.23(79.34%) patientshave favorable outcome with regular follow up. Conclusion- Survival of mucormycosis patients depends on the their good glycemic control,immune status, laterality of the orbital involvement and early detection of intracranial extensionof the disease.With prompt medical (high dose intravenous amphotericin B) and early aggressive surgical intervention involving FESS and orbital exenteration can preventintracranial extension and may improve survival rate .Intracranial extension of the disease has invariably been associated with high mortality.

Direct Fixation of Fractures of the Posterior Malleolus Through a Postero-Medial Approach

Abstract Background and objective: Fractures of the posterior malleolus have long been neglected in the past. The decision for their fixation should be based on plain lateral radiographs. Recent studies have emphasized the important biomechanical function of the posterior tibial ridge. This has caused a trend towards more aggressive surgical treatment. The aim of this study was to present our experience with the direct fixation of complex ankle fractures engaging the posterior malleolus. We also tried to clarify the advantages and limitations of the posterior-medial surgical approach. Materials and Methods: For a period of 1,5 years we have operated 14 patients with posterior malleolus fractures. Their average age was 51 years. Eight of the patients were male, the rest 6 were females. Fractures were classified according to Bartoníček classification system. All patients had type 3 fractures. Direct open reduction was performed in all cases. Posterior buttress plate was used for the fixation of the fracture. Bone grafting was found necessary in one case. Functional assessment was done according to the criteria of the AOFAS (American Orthopedic Foot and ankle score). Follow up was done for an average period of 10 months. Results: All fractures united for an average period of 9 weeks (8-10 weeks). Six patients achieved an excellent functional result, 5 – a good one and 3 had an average result. The average AOFAS rating score was 84,02 (54-100). The average range of motion was 38° (15°-50°). There were no deep infections or septic arthritis. Three ankles had superficial skin necrosis that healed without any additional procedures. One patient had prolonged and substantial swelling of the leg, despite of the routine antithrombotic prophylaxis. Five patients needed their fibular plates removed due to local irritation. Conclusion: The direct reduction and fixation of the posterior malleolus fractures allow anatomical restoration of the ankle mortise. This is a prerequisite for an optimal functional recovery and appears to be a safe treatment strategy.

Early Surgery Prolongs Professional Activity in IDH Mutant Low-Grade Glioma Patients: A Policy Change Analysis.

BackgroundUntil 2015, Dutch guidelines recommended follow-up and biopsy rather than surgery as initial care for suspected low-grade gliomas (LGG). Given evidence that surgery could extend patient survival, our center stopped following this guideline on January 1, 2010 and opted for early maximal safe resection of LGG. The effects of early surgery on the ability of patients to work remains little documented.MethodsA total of 104 patients operated on at our center between January 2000 and April 2013 and diagnosed with the WHO 2016 grade 2 astrocytoma, IDH mutant or oligodendroglioma, IDH mutant and deleted 1p19q were included. The clinical characteristics, survival, and work history of patients operated on before or after January 2010 were obtained from the patients’ records and compared. The minimal follow-up was 8 years.ResultsAs per policy change, the interval between radiological diagnosis and first surgery decreased significantly after 2010. Likewise, before 2010, 25.8% of tumors were initially biopsied, 51.6% were resected under anesthesia, and 22.5% under awake conditions versus 14.3%, 23.8%, and 61.9% after this date (p < 0.001). The severity of permanent postoperative neurological deficits decreased after 2010. In total, 82.5% of the patients returned to work postoperatively before 2010 versus 100% after 2010. The postoperative control of epilepsy increased significantly after 2010 (74.4% vs. 47.9%). The median time from diagnosis to a definitive incapacity to work increased by more than 2 years after 2010 (88.7 vs. 62.2 months).ConclusionA policy shift towards early aggressive surgical treatment of IDH mutant LGG is safe and prolongs the patients’ ability to work.

Importance of early diagnosis and surgical treatment of calcified amorphous tumor-related native valve endocarditis caused by Escherichia coli: a case report

BackgroundUnlike Escherichia coli bacteremia, which is common, E. coli endocarditis is uncommon, particularly in patients with native valve, leading to its delayed diagnosis.Case presentationWe present a case of infective endocarditis caused by E. coli in a 78-year-old Japanese man with type 2 diabetes, involving persistent bacteremia and vegetation on the mitral valve (measuring 18 × 4.2 mm in diameter). He presented with recurrent fever after antimicrobial treatment for pyelonephritis. He received antibiotic therapy for 6 weeks and required surgical removal of a calcified amorphous tumor and vegetation with mitral valvuloplasty 7 days after admission. Despite an episode of multiple cerebral infarctions, he recovered fully from the infection.ConclusionsFollow-up blood cultures should be performed for Gram-negative bacilli bacteremia among patients with unknown focus and an atypical clinical course after treatment. Early diagnosis and aggressive surgical intervention are paramount to achieving good clinical outcomes.

Two cases of resected gallbladder carcinosarcoma with a contrasting course.

IntroductionCarcinosarcoma of the gallbladder is a rare tumor with both carcinoma and sarcoma components.Case presentationIn this paper, we report two cases. The first case is of a man in his 60s who was preoperatively diagnosed with gallbladder carcinosarcoma and has achieved 6 years and 6 months survival through aggressive surgical treatment. The second case is of a woman in her 70s who was diagnosed with locally advanced gallbladder cancer; she underwent multidisciplinary treatment for the same, but died 8 months after the surgery. While the primary disorder was the same in both cases, the clinical courses contrasted sharply.DiscussionThere is no established chemotherapy or radiation therapy for gallbladder carcinosarcoma, and the only curative treatment is surgery. However, it has a very poor prognosis.ConclusionCarcinosarcoma of the gallbladder may progress very rapidly, and the treatment management should be carefully decided.

Surgical Interventions in Cases of Esophageal Hiatal Hernias among Older Japanese Adults: A Systematic Review.

Background and Objectives: Given Japan’s superaging population, an increasing number of older adults in the country need surgical treatment for esophageal hiatal hernias. Accordingly, this systematic review examines surgical interventions for symptomatic esophageal hiatal hernias in older Japanese patients and explores treatment outcomes. Materials and Methods: Articles on single operations for hiatal hernias published after 1991 were found on Google Scholar and Ichushi using specific keywords. Subsequently, articles fulfilling the predetermined inclusion criteria were considered in the study. Results: The mean patient age was 81.4 years, and the male-to-female ratio was 1:11.5. The main reasons for surgery were vomiting, dyspnea, and chest tightness. In terms of hernia classification, type IV was the most common (48%). Surgical modalities were laparoscopy in 15 cases, and laparotomy in 10 cases. Mean postoperative course was 26.47 days until hospital discharge, and there were no cases of perioperative death. Conclusions: Findings showed that multiple factors were involved in older adults’ prognoses, and age was not the only biological factor. Therefore, aggressive surgical intervention should be considered for symptomatic older patients, even in the absence of surgery indicators.

P030 Distinct molecular profiles between idiopathic cryptoglandular and Crohn-related perianal fistulas

Abstract Background Perianal fistula can originate idiopathically (cryptoglandular fistula) or can be a representation of underlying Crohn’s disease (CD). In case of idiopathic fistula, the cryptoglandular theory suggests their development from the anal glands. In contrast, the pathophysiology of CD-related fistula is very poorly understood. Hence, we molecularly characterised and compared the fistula tract in both conditions. Methods We collected surgical biopsies from the fistula tract in 70 CD patients with active draining perianal fistula and in 12 patients with cryptoglandular non-CD related, active draining fistula, all requiring surgical examination under anaesthesia. RNA was sequenced using Illumina HiSeq4000, and these data were analysed through differential gene expression analysis (DESeq2). A false discovery rate (FDR) of 0.05 and a |log 2-fold change (log2FC)| &amp;gt;1 was considered significant. Pathway analysis was performed using IPA (Qiagen). In addition, cellular deconvolution methods (xCell) were applied to study the cellular composition. Results Gene expression analysis identified 1087 genes being differentially expressed between CD-related and cryptoglandular fistula (716 up, 371 down). Top differentially expressed genes encode proteins implicated in IBD pathogenesis including CARD18 (log2FC= 23.2, p=3.9E-21), BATF2 (log2FC=2.8, p=1.8E-8), ETV7 (log2FC=2.1, p=2.0E-7), DSG1 (log2FC=7.8, p=2.7E-6) and IL22RA1 (log2FC=5.3, p=4.6E-6). Additional pathway analysis highlighted various proinflammatory processes in CD fistula (as compared to cryptoglandular fistula), including upregulation of antigen presentation and Th1/Th2 activation (p&amp;lt;1.0E-9). Intriguingly, CD fistula showed a significant downregulation of wound healing signaling pathways (p=6.5E-6), emphasising the refractory character of this debilitating condition. Upstream analyses showed an increased activation of top regulators IFNγ, TNF, LPS and STAT1 (p&amp;lt;1.0E-24). Cellular deconvolution identified significant differences between both fistula types, with a predominance of inflammatory cells in CD including Th1 cells, dendritic cells, naïve CD4 T cells, memory B cells and central memory CD8 and CD4 T cells (p&amp;lt;5.0E-2). In contrast, cryptoglandular fistula were characterised by a significant enrichment of myocytes, smooth muscle cells and neurons (p&amp;lt;3.0E-3). Presence of neutrophils, wound healing and pro-inflammatory macrophages did not differ between both fistula types. Conclusion CD fistulas have a strong proinflammatory fingerprint, but seem to have lower wound healing capacity as compared to cryptoglandular fistula. An aggressive medical and surgical treatment is therefore required, including the search for novel, powerful anti-inflammatory and wound healing compounds.

¿Son los colgajos toracoabdominales una herramienta útil en el tratamiento del carcinoma de mama avanzado?

Despite advances in the treatment of breast cancer, there are cases in which the disease occurs in advanced stages and requires aggressive surgical treatments that cause large defects in the chest wall. Within the different techniques included in oncoplastic surgery, the thoracoabdominal flaps, included in the group of rotation flaps, have been postulated as an attractive technique to cover the wide defects resulting from these extensive surgeries, in order to start adjuvant treatment earlier and improve survival without increasing morbidity. It is important to establish a correct indication and an exhaustive knowledge of the anatomy in order to achieve a simple closure of the defect with good skin coverage.

Prognostic Nomogram and Therapeutic Option of Cancer-Specific Death in the Patients with Metachronous Second Primary Lung Cancer.

With the increase of long-term primary lung cancer survivors, studies focused on metachronous second primary lung cancer (SPLC) have become very urgent. This study aimed to develop a prognostic nomogram and determine therapeutic options of cancer-specific death for patients with metachronous SPLC with and without the competing risk of other-specific death. Study population came from the SEER-18 database between 2006 and 2016. According to the clinical practice guideline of SPLC, the interval time of IPLC and metachronous SPLC was set to 4 years. We constructed nomograms with Lasso + Cox regression model and competing risk model to predict the prognosis and identify therapeutic options of metachronous SPLC patients with the assessment of model performance by the C-index, calibration plot, and decision curve analysis. In addition, two subgroup analyses stratified by histology and tumor size were used to better select therapeutic options for a certain population. 1300 patients with metachronous SPLC were incorporated in this study with 50.1% of the 5-year cumulative incidence in cancer-specific death. Compared with Lasso + Cox regression analysis, competing risk analysis harbored a higher C-index (0.811 vs. 0.76) and better net benefit in predicting cancer-specific death of metachronous SPLC. Two statistical analyses suggested that surgery alone was a preferentially therapeutic option of metachronous SPLC, whereas the effect of surgery + radiation in treating metachronous SPLC was similar to radiation alone. Subgroup analyses indicated that patients with metachronous SPLC were considered receiving different therapeutic options in different histology and tumor size but preferred to receive surgical treatment as the first choice. For primary lung cancer survivors, aggressive surgical treatment was the first-line selection of metachronous SPLC, followed by radiation alone, surgery + radiation, and no surgery + radiation.

Optimal Surgical Extent in Patients with Unilateral Multifocal Papillary Thyroid Carcinoma.

Simple SummaryAround 30% of patients with papillary thyroid cancer (PTC) have multifocality. As tumor multifocality could increase the risk of recurrence in patients with PTC, more aggressive treatments, including total thyroidectomy and higher-dose radioiodine, are commonly used to treat patients with multifocal PTC. However, it is unclear whether aggressive treatment can decrease the risk of recurrence. Our study of 718 patients demonstrated that thyroid lobectomy showed comparable recurrence-free survival to that of total thyroidectomy. Moreover, our findings indicated that thyroid lobectomy could be safely performed on multifocal PTC patients with high-risk factors, such as large tumor size or lymph node metastasis. In conclusion, thyroid lobectomy was not associated with the risk of recurrence in patients with multifocal PTCs. Multifocality in PTC may not always require aggressive surgery.Multifocality increases the risk of recurrence in patients with papillary thyroid carcinoma (PTC); however, it is unclear whether multifocality justifies more extensive or aggressive surgical treatment. Here, we evaluated the effect of the operative extent on the recurrence-free survival (RFS) of patients with multifocal PTC. Between 2010 and 2019, 718 patients with unilateral multifocal PTC were enrolled; 115 patients (16.0%) underwent ipsilateral thyroid lobectomy, and 606 patients (84.0%) underwent total thyroidectomy. With a mean follow up of 5.2 years, RFS was comparable between the total thyroidectomy and lobectomy groups (p = 0.647) after adjusting for potential confounders. Multivariable Cox regression analysis also demonstrated that the operative extent was not an independent predictor of recurrence (HR 1.686, 95% CI: 0.321–8.852). Subgroup analyses further indicated that both total thyroidectomy and thyroid lobectomy resulted in comparable RFS for multifocal PTC patients with other high-risk factors, including tumor size > 1 cm (p = 0.711), lymph node metastasis (p = 0.536), and intermediate ATA risk of recurrence (p = 0.682). In conclusion, thyroid lobectomy was not associated with the risk of recurrence in patients with multifocal PTCs. Multifocality in PTC may not always require aggressive surgery.

Increased Risk of Meconium-Related Ileus in Extremely Premature Infants Exposed to Antenatal Magnesium Sulfate

Introduction: We experienced an increased incidence of meconium-related ileus (MRI) in extremely premature infants (EPIs) while adopting the antenatal magnesium sulfate (MgSO4) protocol for fetal neuroprotection in our neonatal intensive care unit. This study aimed to test whether antenatal MgSO4 use was associated with increased risk of MRI in EPIs. Methods: The incidences of complicated MRI requiring aggressive enema or surgical intervention and other intestinal complications were compared among period 1 (January 2012–December 2013, n = 79), before adoption of the antenatal MgSO4 protocol for fetal neuroprotection; period 2 (January 2014–March 2016, n = 72), when the protocol was adopted; and period 3 (April 2016–September 2018, n = 75), when the protocol was temporarily withdrawn due to concern regarding intestinal complications in EPIs. Results: Despite similar baseline clinical characteristics among infants across the study periods, the MRI and MRI with surgical treatment incidences were higher in period 2 than those in periods 1 and 3 (13% vs. 8% and 6%, p = 0.391, and 11% vs. 0% and 1%, p = 0.001, respectively). In multivariable analysis, exposure to antenatal MgSO4 independently increased the risk of MRI (adjusted odds ratio, 3.8; 95% confidence interval, 1.4, 10.6). Conclusion: Antenatal MgSO4 may increase the risk of MRI, frequently requiring surgical intervention, in EPIs with a gestational age of 25 weeks or less.

Deep Neck Abscess

Background: Deep neck abscess is a life-threatening clinical entity. It can result in significant morbidity for the patients. Deep neck abscess continues to be commonly found in developing countries like India. Methods: A retrospective study was conducted at tertiary care teaching hospital in eastern India from September 2016 to October 2021. The medical records of patients diagnosed with deep neck abscesses with an age range between 18 years and 65 years were reviewed. This study analyzes the etiology, clinical manifestations, diagnosis, and treatment of the deep neck abscess. Results: There was a predominance of male patients with deep neck abscesses (62.12%) and a mean age of 32.4 years. The most common clinical manifestation was fever (26.51%), followed by odynophagia (23.48%), neck swelling (20.45%), restricted neck movement (13.63%), otalgia (12.12%), trismus (11.36%), neck pain (10.60%), and stridor (2.27%). The peritonsillar abscess (28.78%) was the most commonly affected space of the deep neck abscess of this study. The important life-threatening complication in this study was stridor (2.27%). Conclusion: Early diagnosis, aggressive surgical intervention, and proper airway management are important factors for reducing the morbidity and mortality associated with deep neck abscesses.