Benefits Of Surgical Intervention Research Articles

Management of facial nerve trauma.

To present the current literature on management of facial nerve disorder secondary to trauma, with a focus on the utility of electrodiagnostic testing in this setting. Patients with facial palsy related to temporal bone fractures should be started on high-dose corticosteroids as early as possible. Recent literature on the benefit of surgical intervention in the setting of temporal bone fracture is mixed. Some studies support early surgical decompression whereas others have found no benefit compared with conservative treatment. The management of facial nerve trauma is based on location and extent of injury. Extratemporal trauma and transected nerve should be treated with surgical exploration and tension-free coaptation ideally within 72 h. There are no guidelines for intratemporal facial nerve trauma. Surgical decompression compared with medical management is debated in the literature without consensus and more large studies are needed.

Non-metastatic hip fractures surgery in patients with active cancer: benefit and risk.

Although rare, non-metastatic proximal femoral fracture (PFF) can develop in patients with active cancer. However, little data are available regarding the risks and benefits of surgical treatment in such patients. The purpose of his study was to investigate the risks and benefits of surgical treatment of PFF in patients with and without cancer. We retrospectively examined the medical records of all patients treated for PFF, excluding those with pathological fracture, at our hospital from July 2013 to December 2020. The patients were divided into two groups; The active cancer group and the standard group. We investigated in both groups about surgical and medical complications during the perioperative period, walking ability two weeks postoperatively, and one-year postoperative mortality rate. After the inclusion and exclusion criteria, 39 patients in the active cancer group and 331 patients in the standard group were finally investigated. There were no statistically significant differences between the two groups. The complication rate did not appear statistical significance between two groups (16.7% in active cancer group vs 10.7% in standard group: p = 0.272). Walking ability was also similar in two groups. Mortality rate at one year was significantly higher in the active cancer group. (41.2% in active cancer group vs 6.0% in standard group: p < 0.05). Although the active cancer group had a higher mortality rate at one year, which was influenced by the prognosis of the cancer, the benefits of surgical intervention, such as regaining walking ability, were the same in patients with and without active cancer.

Sagittal alignment in operative degenerative lumbar spondylolisthesis: a scoping review.

The benefit of surgical intervention over conservative treatment for degenerative lumbar spondylolisthesis (DLS) patients with neurologic symptoms is well-established. However, it is currently unclear what breadth of available evidence exists on regional and global sagittal alignment in DLS surgery. As such, the purpose of the current study is to conduct a scoping review to map and synthesize the DLS literature regarding the current radiographic assessment of sagittal spinal alignment in DLS surgery. A comprehensive search of the MEDLINE, EMBASE and Cochrane databases from January 1971 to January 2023 was performed for all DLS studies examining sagittal spinal alignment parameters with DLS surgery according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) protocol. From 2,222 studies, a total of 109 studies were included, representing 10,730 patients with an average age of 63.0 years old and average follow-up of 35.1 months postoperatively. Among included studies, 93 (85%), were largely published in the last decade and predominantly represented retrospective cohorts 70 (64%) or case series 22 (20%). A common theme among the reporting of radiographic parameters in the included investigations was the assessment of the magnitude and/or maintenance of a radiographic change postoperatively, with 92 (84%) studies reporting these findings. The majority of studies focused on index DLS level [33 (30%) studies] or lumbar spine radiographic imaging [33 (30%) studies] only. Thirty-seven (34%) studies reported spinopelvic parameters, with only 13 (12%) of included studies assessing 36-inch standing lateral radiographs and overall alignment. There is increasing prevalence of investigations assessing sagittal spinal alignment parameters in DLS surgery. Although, there is an increasing prevalence of studies investigating sagittal spinal alignment parameters in DLS surgery the quality of the currently available literature on this topic is of overall low evidence and largely retrospective in nature. Additionally, there is limited analysis of global sagittal spinal alignment in DLS suggesting that future investigational emphasis should prioritize longitudinally followed large prospective cohorts or multi-centre randomized controlled trials. Attempts at standardizing the radiographic and functional outcome reporting techniques across multi-centre investigations and prospective cohorts will allow for more robust, reproducible analyses of significance to be conducted on DLS patients.

Inflammatory markers may predict post-operative complications and recurrence in Crohn's disease patients undergoing gastrointestinal surgery.

Most Crohn's Disease (CD) patients will require surgical intervention over their lifetime, with considerably high rates of post-operative complications. Risk stratification with reliable prognostic tools may facilitate clinical decision making in these patients. Blood cell interaction based inflammatory markers have proven useful in predicting patient outcomes in oncological and benign diseases. The aim of this study was to investigate their prognostic value in CD patients undergoing surgery. A retrospective single institution study of CD patients who underwent surgery between the years 2008 and 2019 was conducted. Data were collected from medical records and analysed for association of Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Lymphocyte-to-Monocyte Ratio (LMR) and the modified Systemic Inflammatory Score (mSIS) with post-operative outcomes. A total of 81 patients were included in the analysis. Half were females; mean age was 36 ± 15.54 years. Fifty seven percent (n= 46) were operated in expedited settings, with 23.5% developing post-operative complications. In elective patients, higher pre-operative NLR (P= 0.029) and PLR (P= 0.034) were associated with major post-operative complications, higher NLR (P= 0.029) and PLR (P= 0.034) were associated with re-operation and higher PLR correlated with Clavien-Dindo score (P= 0.032). In patients operated in expedited operations, higher pre-operative NLR (P= 0.021) and lower pre-operative LMR (P= 0.018) were associated with thromboembolic events and higher mSIS was associated with major post-operative complications (P= 0.032). Blood cell interaction based inflammatory markers confer an association with post-operative complications in CD patients undergoing surgery. These indices may facilitate patient selection and optimization when considering the risks and benefits of surgical interventions.

EDITORIAL COMMENT

Health literacy has been increasingly identified as a significant contributor to health-related outcomes. Increasing attention has been drawn to its impact on healthcare utilization, complication rates, all-cause mortality, and patient satisfaction. 1 Roy M Corkum JP Urbach DR et al. Health literacy among surgical patients: a systematic review and meta-analysis. World J Surg. 2019; 43 (PMID: 30105637): 96-106https://doi.org/10.1007/s00268-018-4754-z Crossref PubMed Scopus (12) Google Scholar Despite the profound impact on health outcomes, the effects of health literacy on the surgical population remains an understudied topic, with only a few urologic studies published to date. 2 Chang ME Baker SJ Dos Santos Marques IC et al. Health literacy in surgery. Health Lit Res Pract. 2020; 4 (PMID: 32053207; PMCID: PMC7015264): e46-e65https://doi.org/10.3928/24748307-20191121-01 Crossref PubMed Scopus (21) Google Scholar ,3 Jamieson SC Mallory CW Jivanji DR et al. The role of health literacy in prostate cancer screening. Urology. 2021; (S0090-4295(21)00735-4Epub ahead of print. PMID: 34375651)https://doi.org/10.1016/j.urology.2021.05.100 Abstract Full Text Full Text PDF Scopus (1) Google Scholar Elucidating the impact of health literacy among surgical patients is paramount as patients navigate complex decision-making, including understanding the risks and benefits of surgical interventions, and adherence to perioperative and post-operative instructions.

113: THE PARA-OESOPHAGEAL HERNIA SYMPTOM TOOL (POST): A MODIFIED DELPHI CONSENSUS STUDY

Abstract Background and aim Patients with a para-oesophageal hernia (POH) report a range of symptoms and quality of life (QOL) issues. Clinicians often utilise existing health-related quality of life tools to identify patients eligible for surgical management and to evaluate the benefit of surgical intervention. However, the most commonly used tools for this purpose are not disease specific. Therefore, crucial POH-specific symptoms which impact QOL may not be captured. To address this, a modified Delphi consensus study was undertaken to establish a HRQOL instrument specific to POH. Methods A two-round modified Delphi consensus study was conducted with a group of international experts. Participants were identified through their authorship in landmark POH studies and the professional networks of the study investigators. Before the Delphi process, a scoping survey was undertaken to generate a list of candidate items. Participants were asked to rate the items’ importance in assessing patients with POH using a 5-point Likert scale. The a priori threshold for inclusion was 80% for scores of 4 or 5. If consensus was not achieved, the item was carried through to the next round. Results The candidate list of items consisted of 64 symptoms, refined to 20 for inclusion within the first modified Delphi round. Four symptoms; ‘difficulty getting solid foods down’, ‘chest pain after meals’, ‘difficulty getting liquids down’ and ‘shortness of breath only after meals’, reached consensus threshold of 80% in the first round and additionally, ‘early feeling of fullness after eating’, reached consensus in the second. A total of 26 participants took part in the first and 24 in the second round. These five symptoms form the initial version of the Para-Oesophageal Hernia Symptom Tool (POST). Conclusion POST is the first tool that aims to capture POH-specific symptoms that impact HRQOL. Prior to clinical use, this tool will be presented in international patient workshops to assess its construct validity. Thereafter, we aim to assess the content validity of the tool through a longitudinal study in a cohort of patients with undergoing POH repair. This tool aims to serve as a decision-support tool for clinicians when evaluating the risk–benefit of surgical intervention in this cohort of patients.

The wider societal benefits of surgical interventions for lymphatic filariasis morbidity management and disability prevention.

The wider societal benefits of surgical interventions for lymphatic filariasis morbidity management and disability prevention.

COMPLICATIONS OF ARTHROSCOPIC DRILLING IN THE TREATMENT OF OSTEOCHONDRITIS DISSECANS OF THE KNEE IN CHILDREN AND ADOLESCENTS

Background:Arthroscopic drilling is a well-established treatment for stable intact OCDs of the knee in children when non-operative treatment fails. The decision to proceed to operative treatment requires a discussion regarding the risks and benefits of surgical intervention. While there is abundant data suggesting that OCD drilling is a highly effective treatment strategy, there is little data specifically evaluating the risks and complications of this procedure.Purpose:The goal of this study was to assess the complications of drilling of stable OCDs of the knee, and the risk factors for developing complications.Methods:In a retrospective chart review from 2009-2017, data from patients <18 years old who underwent arthroscopic drilling for stable intact OCD lesions of knee were collected. Lesions treated with other techniques (fixation, chondroplasty, OATS), and those with <3 months of follow-up were excluded. Characteristics of the lesions, treatment approach, and post-operative course were recorded. For bilateral surgeries, each knee was considered a separate record.Results:139 knees in 131 patients were evaluated, of which 102 (73%) were male. The mean age was 12.7years. 108 knees (77%) had an open physis at the time of operation. Patients were managed conservatively for a mean of 6.76 months pre-operatively (SD=6.6). Average follow-up was 14.8 months after the initial surgery (SD=13.25). 53 patients (38%) were obese or overweight at the time of surgery. All patients regained full ROM within 5° of the contralateral knee at a mean 12.9 weeks post-op (SD=3.2), with all but 7 (5 %) returning to activities of daily living at the 3-month visit. No cases of infection, stiffness, arthrofibrosis, or other procedure-related complications were recorded. 6 knees (4.3%) underwent 7 additional surgeries during the follow-up period, all of which were for treatment failure in non-healing lesions (loose body removals, chondroplasty, or repeat drilling). In a multiple logistic regression model, age, gender, status of the physis at the time of surgery, BMI percentile, and OCD size were not predictive of the need for additional surgeries.Discussion:Our findings suggest that arthroscopic drilling for OCDs of the knee is a safe procedure with minimal risk of complications. The majority of patients return to their pre-operative daily activity level with full ROM by 3 months after surgery. Complications, including reoperation, were related to the progression of the OCD, rather than the surgical procedure.

Identification of Body Dysmorphic Disorder in Patients Seeking Corrective Procedures From Oral and Maxillofacial Surgeons.

Body dysmorphic disorder (BDD) is an obsessive-compulsive related disorder characterized by an individual's preoccupation with the appearance of at least 1 perceived physical flaw. The bodily concerns held by individuals with BDD are largely unnoticeable, if at all, to other individuals. Those living with BDD are compelled to engage in repetitive behaviors or cognitive acts that interfere with daily function and activities. Despite the high prevalence of BDD in patients who seek cosmetic procedures (ie, as high as 1 in 5 such patients) and the availability of validated screening tools for this disorder, implementing a protocol of regularly screening for BDD is only rarely practiced by surgeons. Few studies have investigated its prevalence in the setting of elective dentoalveolar and orthognathic procedures. With the scope of practice of maxillofacial surgeons expanding in recent years to include facial cosmetic procedures, it is becoming increasingly important to screen for such disorders so that patients and physicians can appropriately weigh the risks and benefits of surgical intervention. We conducted a cross-sectional cohort study (n = 46) consisting of 3 groups of patients, who were seeking either facial cosmetic, orthognathic, or dentoalveolar procedures. All patients in the study were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ) and assessed for severity of disorder using the BDDQ severity scale. Additional patient variables included age, sex, history of psychiatric diagnosis, primary diagnosis, and type of operation/procedure being sought. Among the 3 groups, patients seeking dentoalveolar surgery were the most represented (67%) in this sample, followed by cosmetic surgery (27%) and orthognathic surgery (6%). Twenty-six female participants and 20 male participants were included, with an overall mean age of 38 years. Two percent of participants carried a previous psychiatric diagnosis and 10.8% of the sample were classified as high-risk for BDD. The group containing the highest proportion of patients at high-risk for BDD were those seeking facial cosmetic procedures (16.7%), followed by those seeking dentoalveolar procedures (10%); none of the patients seeking orthognathic procedures were found to be at high-risk for BDD (0%). The BDDQ is an efficient way to screen for BDD in patients who are seeking orthognathic or facial cosmetic surgery. In our sample, patients presenting to maxillofacial surgeons for facial cosmetic surgery were found to score significantly higher on the BDDQ than those presenting for dentoalveolar surgery. In contrast to results of previous literature, patients seeking orthognathic surgery in our sample demonstrated no elevated risk for BDD, a finding which may be attributable to our small sample size. Ultimately, the data obtained from this study can aid surgeons in identifying patients with BDD in their own surgical practice, so that they may appropriately triage patients who may, or may not, benefit from surgical intervention.

Abstract 15087: Identifying Clinical Predictors of Mortality After PCI and the Impact of Complete Revascularization in Patients With Multi-vessel Coronary Artery Disease

Coronary revascularization for multi-vessel coronary artery disease (mvCAD) can be established through PCI or CABG. The benefit of surgical intervention over PCI has been attributed, in part, to more complete revascularization. However, among patients treated with PCI in the present era of drug-eluting stents, it is important to understand whether the completeness of revascularization is associated with mortality. Further, it is important to investigate this relationship in specific patient populations to determine which patients, if any, derive a survival benefit from complete revascularization. Moreover, it is critical to identify which factors are associated with higher mortality in this population to pinpoint potential areas of intervention to mitigate risk. In this propensity-score adjusted analysis, outcomes among 1,580 mvCAD patients who underwent PCI were analyzed and stratified by complete versus incomplete revascularization. The primary outcome was all-cause mortality. Complete revascularization was achieved in 28.4% of the cohort. Complete revascularization was not independently associated with survival compared with incomplete revascularization in the overall cohort (p=0.16). The predictors of increased all-cause mortality included advanced age, chronic lung disease, cardiogenic shock, diabetes, renal insufficiency, reduced left ventricular function, and left main stenosis. Complete revascularization was associated with reduced all-cause mortality in specific patient subsets including those with congestive heart failure and chronic lung disease. Our analysis elucidated numerous clinical predictors of all-cause mortality for mvCAD patients undergoing PCI. Complete revascularization was not among the independent predictors of mortality in the overall population and was associated with reduced mortality in patients with chronic lung disease, history of congestive heart failure and those who did not have previous PCI. While this study was not designed to test whether complete revascularization was superior to incomplete revascularization, the results suggest that when PCI is pursued among patients with mvCAD, achieving complete revascularization does not contribute to increased mortality.

Association between surgical treatment and in-hospital mortality in patients with infective endocarditis stratified by NYHA classification: a nationwide retrospective study in Japan

Abstract Background Heart failure (HF) is one of the major complications of infective endocarditis (IE). The ESC guideline described that surgical treatment should be performed for the patients with IE complicated with HF. However, decision making of surgical indication in real-world clinical setting is not easy for patients with IE concomitant with HF due to complicated conditions, and the clinical benefit of surgical intervention for IE and HF is unclear. Purpose We sought to uncover the association between surgical treatment and in-hospital mortality among the patients admitted for community-acquired IE respectively according to the severity of HF symptoms (NYHA class I to IV). Methods We studied 3,403 patients diagnosed as IE (mean age 65.9 years, 61.6% males) with records of baseline NYHA classification (I to IV) who survived for more than 2 days, using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Patients were classified into four groups: 919 patients (27.0%) in NYHA I, 1,007 patients (29.6%) in NYHA II, 767 patients (22.5%) in NYHA III, and 710 patients (20.9%) in NYHA IV. A multivariable logistic regression model adjusted for age, gender, Barthel Index, Charlson Comorbidity Index, and usage of inotropic therapy at admission was performed to evaluate the association between the surgical treatment and in-hospital mortality. Results Patients with higher NYHA classification were significantly older and were more likely to be female than those with lower NYHA classification. At admission, patients with higher NYHA classification had lower baseline activities and higher comorbidities, and also had more complications including stroke, shock and disseminated intravascular coagulation than those with lower NYHA classification. In-hospital mortality was seen in 406 patients (11.9%) in the entire cohort. The mortality rate significantly increased with the NYHA class (NYHA I, 3.6%; NYHA II, 8.4%; NYHA III, 11.9%; NYHA IV, 27.9%: p&amp;lt;0.001). According to the multivariable logistic regression analysis, surgical treatment was independently associated with lower in-hospital mortality (Odds ratio 0.395, 95% Confidence Interval 0.297–0.526; p&amp;lt;0.001). A fragmentated analysis in each NYHA classification showed that the survival benefit of surgical intervention was pronounced in patients with higher NYHA class (Figure). The limitation of our study was including the potential unmeasured confounders, which lead to overestimate the relationship between the surgical treatment and in-hospital mortality even after excluding the critically ill patients who died within 2 days and adjusting for the measured confounders. Conclusion Surgical treatment was associated with lower in-hospital mortality among the patients with IE complicated with HF, particularly among those with more advanced HF status. Our study implies that surgical treatment might be beneficial for the patients with advanced HF. Funding Acknowledgement Type of funding source: None

Обзор оценочных шкал и классификаций метастатических поражений позвоночника, используемых при оперативном лечении

It is known that metastases in the spine are detected in more than 70% of cancer patients, and in 10% of such patients, compression of nerve structures and severe neurological disorders develop. The role of surgery for metastatic tumors of the spine is in the focus of attention, since the operation can improve mechanical stability, decompress nerve structures and reduce the intensity of pain. However, what role the operation plays in increasing life expectancy and how to correctly assess the results of treatment remains controversial and the opinions of specialists are controversial, since the assessment is often made by oncologists, but it is the surgeon who more fully evaluates the potential risks and benefits of surgical interventions. Therefore, it is important for surgeons to understand what prognostic factors affect the quality and duration of life. This article presents the most cited classifications and assessments before 2009, as well as all classifications and assessments obtained after 2010 regarding metastatic lesions of the spine, as well as classifications used to develop treatment tactics obtained from the electronic databases PubMed, MEDLINE, articles, monographs, abstracts, dissertations and other sources of scientific and medical information. 57 main publications with II and III levels of evidence were selected, 6 classifications and 24 rating scales were considered. In order to construct the necessary tactics of the surgical strategy, the classification / assessment methods were divided into anatomical classification / assessment methods, neurological symptom / instability assessment methods, and assessment systems for predicting life expectancy. The study showed that in the surgical treatment of metastatic tumors of the spine, it is important to use the same rating scales and classifications to select indications and assess the results of surgical treatment, as well as to achieve meaningful comparisons between published series. Conclusion. The classifications and rating scales used for metastatic lesions of the spine do not fully reflect the type of surgical treatment: there is no algorithm for restoring the support ability of the spine, which is very important for this category of patients

Surgery Combined with Long-Term Imatinib Treatment for Patients with Recurrent or Metastatic Gastrointestinal Stromal Tumors

The first-line treatment for recurrent or metastatic gastrointestinal stromal tumors (GISTs) is imatinib, but the benefit of surgical intervention has not been determined. Surgery combined with long-term imatinib treatment (> 10 years) has rarely been reported. Patients with recurrent or metastatic GISTs who received surgery combined with long-term imatinib treatment (> 10 years) were included in this study. The demographic, surgical, and clinicopathologic data were retrospectively collected and analyzed. Five patients (three men and two women) with a median age of 47 (range 37–72) years were included. The primary tumor was located in the stomach and small intestine in three and two patients, respectively. Four patients who received complete resection (R0) had a single recurrent tumor. The remaining patient had more than two recurrent lesions, and the operation was done with gross residual disease (R2 resection, > 90% of the tumor bulk removed). All patients received more than 10 (median 13.50, range 12.30–13.67) years of imatinib treatment after resection of recurrent tumors. Two patients received a reduced dose of imatinib, and the remaining received 400 mg/day. The median follow-up was 17.0 (range 14.58–20.17) years since the primary tumor was resected. Two patients developed a tumor recurrence after 11.58 and 12.0 years of imatinib treatment, respectively. Surgical intervention may be beneficial when combined with long-term imatinib treatment for selected patients with recurrent or metastatic GISTs but should be further investigated.

Does Mode of Surgical Intervention Based on Oncotype DX Score Influence Disease Recurrence in Early Breast Cancer?

Introduction Routine utilization of multigene assays to inform operative decision-making in early breast cancer (EBC) treatment is yet to be established. In this pilot study, we sought to establish the potential benefits of surgical intervention in EBC based on recurrence risk quantification using the Oncotype DX (ODX) assay. Materials and Methods Consecutive ODX tests performed over a 9-year period from October 2007 to May 2016 were evaluated. Oncotype scores were classified into high (≥31), medium (18–30), or low-risk (0–17) groups. The primary outcome was breast cancer recurrence. Subgroup analysis offered assessment of the recurrence effect of mode of surgical intervention for patient groups as defined by the oncotype score. Results In total 361 patients underwent ODX testing. The mean age and follow-up were 55.25 (± 10.58) years and 38.59 (± 29.1) months, respectively. The majority of patients underwent wide local excision (86.7%) with 8.9 and 4.4% patients having a mastectomy or wide local excision with completion mastectomy, respectively. Fifty-one percent of patients fell into the low risk ODX category with a further 40.2 and 8.5% deemed to be of intermediate and high risk. Five patients (1.38%) had disease recurrence. Comparative analysis of operative groups in each oncotype group revealed no difference in recurrence scores in the low- ( p = 0.84) and high-risk groups ( p = 0.92) with a statistically significant difference identified in the intermediate risk group ( p = 0.002). Conclusion To date we have been unable to definitively identify a role for ODX in guiding surgical approach in EBC. There is, however, a need for larger studies to examine this hypothesis.

Diagnosis and therapy of feedlot lameness

While not at an incidence level comparative to bovine respiratory disease, lameness in feedlots still presents a significant challenge and results in significant economic loss. These proceedings address the basics of diagnosis and therapy of infectious pododermatitis (foot rot), septic arthritis, toe abscesses (toe tip necrosis syndrome), and papillomatous digital dermatitis (hairy heel wart). The benefits of surgical intervention in selected lameness cases are recognized but are beyond the scope of this presentation. Understanding of the causal factors for each disease is pivotal in minimizing additional cases.

Modeling aortorenal perfusion in suprarenal coarctation repair

Suprarenal abdominal aortic coarctation (SAAC) is a congenital midaortic syndrome that develops owing to a developmental anomaly in the fusion of the embryonic dorsal aortae. This condition is associated with severe hypertension, which is usually the indication for intervention. Open surgery is the primary treatment and it typically involves thoracoaortic bypass (TAB), and less commonly patch aortoplasty (PA). Bypass to the visceral vessels has also been performed in conjunction with TAB or PA. The majority undergoing intervention for SAAC are children and adolescents; therefore, the benefits of surgical intervention must be weighed against the risks of surgery on the developing aorta.

Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery

To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.

Upfront Surgical Resection of Melanoma Brain Metastases Provides a Bridge Toward Immunotherapy-Mediated Systemic Control.

Immune checkpoint blockade has systemic efficacy in patients with metastatic melanoma, including those with brain metastases (MBMs). However, immunotherapy-induced intracranial tumoral inflammation can lead to neurologic compromise, requiring steroids, which abrogate the systemic efficacy of this approach. We investigated whether upfront neurosurgical resection of MBM is associated with a therapeutic advantage when performed prior to initiation of immunotherapy. An institutional review board-approved, retrospective study identified 142 patients with MBM treated with immune checkpoint blockade between 2010 and 2016 at Massachusetts General Hospital, of whom 79 received surgery. Patients were classified based on the temporal relationship between immunotherapy, surgery, and development of central nervous system metastases. Overall survival (OS) was calculated from the date of diagnosis of MBM until death from any cause. Multivariate model building included a prognostic Cox model of OS, the effect of immunotherapy and surgical sequencing on OS, and the effect of immunotherapy and radiation sequencing on OS. The 2-year overall survival for patients treated with cytotoxic T-lymphocyte antigen 4, programmed death 1, or combinatorial blockade was 19%, 54%, and 57%, respectively. Among immunotherapy-naïve melanoma brain metastases, surgery followed by immunotherapy had a median survival of 22.7 months (95% confidence interval [CI], 12.6-39.2) compared with 10.8 months for patients treated with immunotherapy alone (95% CI, 7.8-16.3) and 9.4 months for patients treated with immunotherapy followed by surgery (95% CI, 4.1 to ∞; p = .12). On multivariate analysis, immunotherapy-naïve brain metastases treated with immunotherapy alone were associated with increased risk of death (hazard ratio, 1.72; 95% CI, 1.00-2.99) compared with immunotherapy-naïve brain metastases treated with surgery followed by immunotherapy. In treatment-naïve patients, early surgical resection for local control should be considered prior to commencing immunotherapy. A prospective, randomized trial comparing the sequence of surgery and immunotherapy for treatment-naïve melanoma brain metastases is warranted. In this retrospective study of 142 patients with melanoma brain metastases treated with immune checkpoint blockade, the development of melanoma brain metastases following immunotherapy was associated with decreased survival compared with diagnosis of immunotherapy-naïve brain metastases. The benefit of surgical intervention was seen in immunotherapy-naïve brain metastases in contrast to brain metastases that developed on immunotherapy. These results suggest that upfront local control with surgery for immunotherapy-naïve melanoma brain metastasis may provide a bridge toward immunotherapy-mediated systemic control.

Benefits of surgical intervention in locally advanced breast cancer – a Lynch II syndrome case presentation

Benefits of surgical intervention in locally advanced breast cancer – a Lynch II syndrome case presentation

Fatal orbital cellulitis with intracranial complications: a case report

BackgroundOrbital cellulitis is a relatively uncommon presentation in the emergency department, but orbital cellulitis complicated by intracranial extensions, loss of vision, and death has rarely been reported in the literature.Case presentationWe report a 40-year-old Pakistani diabetic male complaining of 5 days of bilateral eye pain, proptosis, ophthalmoplegia, headache, and fever. A diagnosis of orbital cellulitis with intracranial extension was made. A computed tomography (CT) scan and a magnetic resonance imaging (MRI) were done on the patient and showed unremarkable orbits, extensive sinusitis, frontal abscess, and multiple septic emboli. The patient was admitted and on day 9 deteriorated and died.ConclusionOrbital cellulitis associated with intracranial extension is an extremely rare presentation, and the incidence is unknown. The use of contrast-enhanced imaging studies (CT/MRI) early on in the management of suspected orbital cellulitis is supported by the literature. Cerebritis and brain abscesses resulting from orbital cellulitis need advanced care from multidisciplinary teams. Further studies need to be done to provide recommendations on the use and benefit of surgical intervention.