Definitive Surgical Treatment Research Articles

18F-fluorocholine PET/CT imaging in primary hyperparathyroidism after negative or inconclusive cervical ultrasonography and 99mTc-MIBI scintigraphy.

Primary hyperparathyroidism (pHPT) is a common endocrine disorder characterized by one or more hyperfunctioning parathyroid glands. Definitive surgical treatment demands precise preoperative localisation of hyperfunctioning parathyroid tissue. The purpose of our study is to assess the value of 18F-fluorocholine positron emission tomography (PET/CT) in preoperative localisation of hyperfunctioning parathyroid glands in patients with biochemically confirmed pHPT and negative or inconclusive cervical ultrasonography and 99mTc-MIBI scintigraphy. Our study included 167 patients with biochemically confirmed pHPT and negative or inconclusive cervical ultrasonography and 99mTc-MIBI scintigraphy. In our study 18F-fluorocholine PET/CT detection rate was 92.81% (155/167) with 182 lesions identified. Overall sensitivity, specificity, accuracy, and positive predictive value (PPV) on a per-lesion analysis were 100%, 75%, 95.33%, and 94.74%. Ninety (90/95) lesions were 18F-fluorocholine PET/CT true positive. A total of 86 patients underwent surgical procedures in which 95 histological lesions were removed. Histology revealed 60 adenomas, 25 hyperplasias, 5 lesions described as inconclusive parathyroid tissue, benign lymph node tissue in 4 lesions and 1 false-positive lesion was follicular thyroid adenoma. After surgery, all patients had PTH serum values measured (15min after extirpation or during immediate postoperative recovery). Mean PTH serum values in patients with successful surgery decreased by an average of 62.54% (preoperative PTH 14.74 ± 8.54pmol/L to 6.3 ± 6.8pmol/L). 18F-fluorocholine PET/CT is an accurate, fast, and highly sensitive method for identifying the localization of overactive parathyroid glands in patients with primary hyperparathyroidism.

Retroperitoneal pancreas transplantation with a Roux-en-Y duodenojejunostomy for exocrine drainage

BackgroundPancreatic transplantation is the only definitive surgical treatment for diabetes mellitus. Currently, most transplant centers use enteric exocrine drainage of pancreatic secretions; however, experts disagree on which part of the gastrointestinal tract is preferable for enteric anastomosis. We analyzed the outcomes of retroperitoneal pancreatic transplantation with enteric drainage of pancreatic secretions.Materials and methodsWe evaluated the outcomes of 60 simultaneous retroperitoneal pancreas-kidney transplantations. Based on the type of enteric anastomosis, the patients were divided into two groups: the study group consisted of 10 patients who underwent enteric drainage via Roux-en-Y duodenojejunostomy, and the control group included 50 patients who underwent exocrine drainage via duodenoduodenal anastomosis. No statistically significant differences were observed between the groups in terms of the main parameters.ResultsThe rate of surgical complications did not differ significantly between the groups (p > 0.05). Clavien IVb complications occurred only in the control group (n = 4.8%). The in-hospital pancreatic graft survival rate in both groups was 80%, whereas the recipient survival rates were 90% and 84%, in the study and control groups, respectively (p < 0.05).ConclusionRetroperitoneal pancreatic transplantation with exocrine drainage via a Roux-en-Y duodenojejunostomy is an effective alternative technique that reduces the rate of severe surgical complications.

EGS SO28 - Management of oesophageal diverticulitis in a 71-year-old female: Case report and review of management approaches

Abstract Background Oesophageal diverticulitis is a rare condition with fewer than ten reports in the literature. We present a case of oesophageal diverticulitis in a 71-year-old female with a history of COPD, TIA, and known oesophageal diverticulum. She was managed conservatively with NBM, total parenteral nutrition and intravenous antibiotics requiring a 16-day inpatient stay. The rarity of this condition poses challenges in its diagnosis and management, necessitating a thorough understanding of both conservative and surgical interventions. This case highlights the complexity involved in treating oesophageal diverticulitis, especially in patients with significant comorbidities. Method Patient presented with a 6-day history of upper abdominal pain and sepsis (elevated inflammatory markers; CRP 320, WCC 11.1, temperature 38.0, pulse 104). Abdomen was soft with upper abdominal tenderness. Imaging was consistent with diverticulitis of a 5.9cm lower oesophageal diverticulum without perforation. Initial management included making the patient nil by mouth, total parenteral nutrition, and intravenous antibiotics (vancomycin and metronidazole). The patient’s condition was closely monitored with serial blood tests and clinical assessments. Opinion was sought from a tertiary upper GI centre. Discharge was planned once the patient safely transitioned to oral diet and was apyrexial for 48 hours. Results Inflammatory markers improved over five days (CRP from 320 to 51, WCC from 11.1 to 9). She remained intermittently pyrexial until day 8 of admission. Clinical improvement allowed transition from intravenous to oral therapy, and she was discharged on day 16 with double dose oral PPI therapy. Patient has been followed up by tertiary upper GI services with plans for consideration of surgical resection of the oesophageal diverticulum. The patient’s successful discharge without surgical intervention during the acute phase underscores the effectiveness of a conservative management approach initially, with a plan for definitive surgical treatment in a stable outpatient setting. Conclusion Oesophageal diverticulitis, though rare, requires a nuanced approach to management, especially in patients with significant comorbidities. This case demonstrates the importance of an awareness of thorough history taking and review of previous examinations to prevent delayed diagnosis of a rare pathology not demonstrated on a CT abdomen and pelvis. This approach highlights the importance of individualised treatment plans and the potential for conservative management to provide stabilisation, followed by elective surgical management. The paucity of cases of oesophageal diverticulitis has prevented development of evidence based guidelines, underscoring the importance of seeking advice from tertiary centers when managing rare presentations.

Pancreatic Heterotopia in the Biliary Cyst Wall of a Pregnant Patient and Literature Review.

Pancreatic heterotopia is the presence of pancreatic tissue in a different anatomical location with no connection to the main pancreas. The most common locations in the gastrointestinal system are duodenum, stomach, and Meckel diverticulum. However, it is quite rare in the hepatobiliary system. Here we present a patient with pancreatic heterotopia who we treated with left hemihepatectomy and extrahepatic bile duct resection for Todani type 4a bile duct cyst. Heterotopic pancreatic tissue was present in dilated cystic bile ducts on pathological examination. A 22-year-old 26-week pregnant patient presented to the emergency department with right upper quadrant pain. There was massive dilatation of the left lobe bile ducts and common bile duct, and multiple stones were observed distal to the common bile duct. The patient was hospitalized for definitive surgical treatment 4 months after giving birth. The patient underwent left hemihepatectomy, extrahepatic bile duct resection, and hepaticojejunostomy. The postoperative course was uneventful. Pathological examination of the specimen showed heterotopic pancreatic tissues in the wall of the dilated cystic intrahepatic and extrahepatic bile ducts. One of the most accepted hypotheses in the etiology of biliary tract cysts involves the abnormal union of the pancreatic duct and common bile duct. This lesion is unique in the absence of pancreaticobiliary junction anomaly. We think that cystic dilation of intrahepatic and extrahepatic bile ducts is likely secondary to recurrent inflammation due to the release of digestive enzymes by heterotopic pancreatic tissue in the biliary tract. It is also the first example in the literature diagnosed during pregnancy.

IMMUNOREACT 8: Immune markers of local tumor spread in patients undergoing transanal excision for clinically N0 rectal cancer

BackgroundTransanal excision of rectal cancer can be considered the definitive surgical treatment if the depth spread is T1 or lower, and the lesion is completely included within the resection margin. This study aims to analyze the immune microenvironment in healthy rectal mucosa as a possible predictor of tumor infiltration depth, lateral tumor spread, and recurrence of rectal cancer after transanal local excision. MethodsThis study is a subanalysis of data from the IMMUNOREACT 1 and 2 trials (NCT04915326 and NCT04917263, respectively) including all the patients who underwent transanal excision of rectal cancer. This multicentric study collected healthy mucosa surrounding the neoplasms of patients with rectal cancer. A panel of immune markers was investigated at immunohistochemistry: CD3, CD4, CD8, CD8β, Tbet, FoxP3, PD-L1, MSH6, and PMS2 and CD80. Flow cytometry determined the proportion of epithelial cells expressing CD80, CD86, CD40, HLA ABC or HLA DR and the proportion of activated CD8+ T cells, CD4+ Th1 cells, and Treg. ResultsReceiver operating characteristic curve analysis for predicting deep tumor spread showed an area under the curve of 0.70 (95% confidence interval: 0.60–0.80) for CD25+FoxP3+ cell rate and 0.74 (95% confidence interval: 0.53–0.92) for CK+CD86+ cell rate. Receiver operating characteristic curve analysis for predicting lateral tumor spread showed an area under the curve of 0.82 (95% confidence interval: 0.61–0.99) for CD8+CD38+ MFI, 0.96 (95% confidence interval: 0.85–0.99) for CD8β infiltration, and 0.97 (95% confidence interval: 0.87–0.99) for CK+HLAabc+ cell rate. Receiver operating characteristic curve analysis for predicting recurrence showed an area under the curve of 0.93 (95% confidence interval: 0.76–0.99) for CD8+CD38+ MFI and 0.94 (95% confidence interval: 0.78–0.99) for CD8+CD28+ MFI. Low CD8+CD38+ MFI and low CD8+CD28+ MFI were associated with shorter disease-free survival (P = .025 and P = .021, respectively). ConclusionOur study showed that the association between the high proportion of epithelial cells acting as presenting cells and deep or lateral tumor spread may be explained by the presence of a greater tumor load at the site. Moreover, it showed that weak activation of CD8+ T cells within the rectal mucosa is associated with lateral tumor spread and eventually a higher recurrence rate. The mucosal level of CD8β infiltration detected at immunohistochemistry might be tested as a marker of lateral tumor spread and potentially translated into clinical practice.

Evaluation and Surgical Management of Pediatric Cutaneous Melanoma and Atypical Spitz and Non-Spitz Melanocytic Tumors (Melanocytomas): A Report From Children's Oncology Group.

The purpose of this study was to develop recommendations for the diagnostic evaluation and surgical management of cutaneous melanoma (CM) and atypical Spitz tumors (AST) and non-Spitz melanocytic tumors (melanocytomas) in pediatric (age 0-10 years) and adolescent (age 11-18 years) patients. A Children's Oncology Group-led panel with external, multidisciplinary CM specialists convened to develop recommendations on the basis of available data and expertise. Thirty-three experts from multiple specialties (cutaneous/medical/surgical oncology, dermatology, and dermatopathology) established recommendations with supporting data from 87 peer-reviewed publications. (1) Excisional biopsies with 1-3 mm margins should be performed when feasible for clinically suspicious melanocytic neoplasms. (2) Definitive surgical treatment for CM, including wide local excision and sentinel lymph node biopsy (SLNB), should follow National Comprehensive Cancer Network Guidelines in the absence of data from pediatric-specific surgery trials and/or cohort studies. (3) Accurate classification of ASTs as benign or malignant is more likely with immunohistochemistry and next-generation sequencing. (4) It may not be possible to classify some ASTs as likely/definitively benign or malignant after clinicopathologic and/or molecular correlation, and these Spitz tumors of uncertain malignant potential should be excised with 5 mm margins. (5) ASTs favored to be benign should be excised with 1- to 3-mm margins if transected on biopsy. (6) Re-excision is not necessary if the AST does not extend to the biopsy margin(s) when complete/excisional biopsy was performed. (7) SLNB should not be performed for Spitz tumors unless a diagnosis of CM is favored on clinicopathologic evaluation. (8) Non-Spitz melanocytomas have a presumed increased risk for progression to CM and should be excised with 1- to 3-mm margins if transected on biopsy. (9) Re-excision of non-Spitz melanocytomas is not necessary if the lesion is completely excised on biopsy.

Bladder Pain Syndrome (BPS): A Comprehensive Review of Treatment Strategies and Management Approaches.

Bladder pain Syndrome presents a multifaceted challenge in contemporary urological practice, marked by LUTS, negative behavioural, sexual, or emotional experiences, and the potential for sexual dysfunction. We meticulously explored the existing literature of conservative, non-invasive and invasive interventions, aiming to provide clinicians with a nuanced understanding of available options for comprehensive BPS management. We delve into the effectiveness and safety profiles from behavioural approaches through lifestyle changes and physical therapy, to oral or intravesical medications, until the definitive surgical treatment. The best option evaluated is the involvement of a multidisciplinary team, including urologists, urotherapists, gynaecologists, pain specialists, primary care physicians and psychologists, educating those patients regarding the condition and its chronic course and tailoring the perfect treatment for each person. Despite this, BPS remains a challenge for urologists. Indeed, our objective is to contribute to the evolving landscape of BPS management, fostering informed decision-making and personalized care for individuals grappling with this challenging condition.

Mirikizumab for the treatment of chronic antibiotic-refractory pouchitis.

The current standard of care for the definitive surgical treatment of complicative ulcerative colitis is a continence-preserving proctocolectomy with the creation of an ileal pouch anal anastomosis. In addition to structural and functional disorders, pouchitis of the J-pouch is a common phenomenon, typically well responsive to antimicrobial therapy. However, sometimes chronic antibiotic-refractory pouchitis occurs, most often due to not completely understood multifactorial pathomechanisms. While high-quality evidence is available only for anti-integrin therapy, the role of advanced therapy, i.e., cytokine-antibodies or small molecules in the treatment of chronic antibiotic-refractory pouchitis (CARP), is emerging.This case demonstrates a successful induction treatment of CARP with the novel p19-selective IL-23-targeted antibody mirikizumab.

Combined pelvic ring and acetabular fractures – strategies and sequence of surgery. State of the art

Combined injuries of the pelvic ring and the acetabulum are uncommon. Acute treatment should follow common protocols (ATLS e.g.) for pelvic ring injuries, although mechanical stabilization using pelvic binders or external fixators might be insufficient or even worsen the reduction in some combined fracture patterns. In case of mechanically connected acetabular and pelvic ring injury (MCAPI), surgical treatment might be demanding in lack of clear recommendations concerning the reduction and fixation sequence. A “pelvic ring first” sequence may be the best choice for most MCAPIs, starting with sacrum or SI-joint and symphysis pubis. An “acetabulum first” sequence should be considered in relatively stable posterior ring injuries and acetabulum fractures in younger patients, where a perfect anatomical reduction is feasible. Definitive surgical treatment should be performed as soon as possible depending on concomitant injuries, ideally within 3–7 days. Mechanical understanding of the combined fracture pattern and accurate planning are mandatory for surgical repair.

Exploring aortic morphology and determining variable-distance insertion lengths for fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta (REBOA)

Background (Rationale/Purpose/Objective)Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporary control non-compressible truncal hemorrhage (NCTH) as bridge to definitive surgical treatment. The dependence on radiography for safe balloon positioning is one factor that limits the extended use of REBOA in civilian and military pre-hospital settings. We aimed to determine standardized sex and age-based variable-distance catheter insertion lengths for accurate REBOA placement without initial fluoroscopic confirmation.MethodsContrast enhanced CT-scans from a representative sample of a Dutch non-trauma population were retrospectively analyzed. Intravascular distances were measured from the bilateral common femoral artery access points (FAAP) to the middle of the aortic occlusion zones and accompanying boundaries. Means and 95% confidence intervals for the distances from the FAAPs to the boundaries and mid-zone III were calculated for all (combined) sex and age-based subgroups. Optimal insertion lengths and potentially safe regions were determined for these groups. Bootstrap analysis was performed in combination with a 40-mm long balloon introduction simulation to determine error-rates and REBOA placement accuracy for the general population.ResultsIn total, 1354 non-trauma patients (694 females) were included. Vascular distances increased with age and were longer in males. The iliofemoral trajectory was 7 mm longer on the right side. The optimal zone I catheter insertion length would be 430 mm. Optimal zone III catheter insertion lengths showed up to 30 mm difference, ranging between 234 and 264 mm. Statistically significant and potentially clinically relevant differences were observed between the anatomical distances and necessary introduction depths for each subgroup.ConclusionThis is the first study to compare aortic morphology and intravascular distances between combined sex and age-based subgroups. As zone III length was consistent, length variability and elongation seem to mainly originate in the iliofemoral trajectory and zone II. The optimal zone I catheter insertion length would be 430 mm. Optimal zone III catheter insertion ranged between 234 and 264 mm. These standardized variable-distance insertion lengths could facilitate safer fluoroscopy-free REBOA in austere, pre-hospital settings.

Return to Activity Following Isolated Ulnar Nerve Surgery: A Systematic Review.

Ulnar neuropathy is one of the more commonly diagnosed mononeuropathies; despite this, a definitive surgical treatment strategy has not been widely agreed upon. In this study, we systematically review the literature and assess return to play or activity outcomes in patients with neuritis or neuropathy undergoing in situ decompression, subcutaneous transposition, or submuscular transposition of the ulnar nerve. We hypothesized that ulnar nerve transposition or decompression in the absence of concomitant ulnar collateral ligament (UCL) pathology would have a high rate of return to activity. Relevant studies were generated from 1975 to 2023 using PubMed, Academic Search Complete, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and SPORTDiscus. Articles reporting on return to play or activity outcomes following isolated ulnar nerve transposition or decompression for ulnar neuritis were included. Studies evaluating patients with concomitant UCL injury or revision surgery were excluded. A total of 12 studies met the inclusion criteria, ranging from 1977 to 2021. There were a total of 358 patients with a reported return to play or activity status across all studies with an average age of 27.2 years (range, 11-75). Successful return to play, activity, or work was reported in 303 patients (84.6%). Patients undergoing transposition, subcutaneous (n = 232) and submuscular (n = 20), had return rates of 87.9% and 95%, respectively. Patients undergoing in situ decompression (n = 106) had return rates of 75.5%. This systematic review found an 84.6% return to activity rate following ulnar nerve transposition or decompression in the absence of concomitant UCL pathology. Overall, transposition or decompression of the ulnar nerve provides a favorable return to activity rates and with appropriate indications and surgical technique will likely yield a successful return.

Clinical Outcomes After Definitive Treatment of Soft Tissue Sarcoma of the Hand: A Retrospective Cohort Study of 109 Patients

The purpose of this study was to provide updated data on oncologic outcomes following definitive surgical treatment of soft tissue sarcoma of the hand in a cohort of 109 patients, as well as to characterize risk factors for poor oncologic and functional outcomes. We analyzed data from 109 consecutive patients who had definitive surgical treatment for soft tissue sarcoma of the hand performed between 1996 and 2019 by a single surgeon at a sarcoma center. Primary outcomes included functional outcome (assessed by Musculoskeletal Tumor Society scores), disease-free survival (DFS), and overall survival (OS). We compiled descriptive data and used a multivariable linear model to identify factors associated with functional outcomes. Kaplan-Meier methods were used to estimate 5- and 10-year DFS and OS. Patients had a median age of 36 years at presentation. Median follow-up was 6.1 years among patients alive at the end of follow-up. The median Musculoskeletal Tumor Society score was 29; functional outcome was worse among patients with high-grade tumors or complications. Among the 107 patients who became disease-free, there were four local recurrences (one with metastasis), six distant recurrences, and one death without recurrence. All local recurrences were deep tumors (two myxofibrosarcoma and two myxoinflammatory fibrosarcoma). Estimated 5- and 10-year DFS rates were 89% (95% confidence interval [CI]: 83% to 96%) and 88% (95% CI: 80% to 95%). There were seven deaths, and the estimated 5- and 10-year OS rates were 95% (95% CI: 90% to 100%) and 92% (95% CI: 84% to 100%). Larger tumor size and higher stage at diagnosis were associated with shorter DFS and OS in univariable analyses; low event rates precluded multivariable analysis of survival. Aggressive disease-specific surgical and multidisciplinary treatment can yield long DFS and OS, and good functional outcomes. However, complications and high-grade tumors are associated with worse functional scores. Prognostic II.

Current Treatment Options: Uterine Sarcoma.

The cornerstone of treatment for uterine sarcoma, regardless of histologic type, remains en bloc surgical resection with total hysterectomy. In the case of incidental diagnosis during another procedure, such as myomectomy, where a hysterectomy was not performed initially, completion hysterectomy or cervical remnant removal is recommended. The completion of additional surgical procedures, including bilateral salpingo-oophorectomy and lymphadenectomy, remains nuanced. Bilateral salpingo-oophorectomy remains controversial in the setting of most subtypes of uterine sarcoma, except in the case of hormone-receptor positivity, such as in low grade endometrial stromal sarcoma, where it is indicated as part of definitive surgical treatment. In the absence of apparent nodal involvement, we do not recommend performing universal lymphadenectomy for patients with sarcoma. We recommend systemic therapy for patients with extra-uterine or advanced stage disease, high-grade histology, and recurrence. The most active chemotherapy regimens for advanced, high-grade disease remain doxorubicin or gemcitabine and docetaxol combination therapy. A notable exception is low grade endometrial stromal sarcoma, where we recommend anti-hormonal therapy in the front-line setting. Radiation therapy is reserved for selected cases where it can aid in palliating symptoms.

Risk Analysis Index as a preoperative frailty tool for elective ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) predominantly occurs in older patients, and ventriculoperitoneal shunt (VPS) placement is the definitive surgical treatment. VPS surgery carries significant postoperative complication rates, which may tip the risk/benefit balance of this treatment option for frail, or higher-risk, patients. In this study, the authors investigated the use of frailty scoring for preoperative risk stratification for adverse event prediction in iNPH patients who underwent elective VPS placement. The Nationwide Readmissions Database (NRD) was queried from 2018 to 2019 for iNPH patients aged ≥ 60 years who underwent VPS surgery. Risk Analysis Index (RAI) and modified 5-item Frailty Index (mFI-5) scores were calculated and RAI cross-tabulation was used to analyze trends in frailty scores by the following binary outcome measures: overall complications, nonhome discharge (NHD), extended length of stay (eLOS) (> 75th percentile), and mortality. Area under the receiver operating characteristic curve analysis was performed to assess the discriminatory accuracy of RAI and mFI-5 for primary outcomes. A total of 9319 iNPH patients underwent VPS surgery, and there were 685 readmissions (7.4%), 593 perioperative complications (6.4%), and 94 deaths (1.0%). Increasing RAI score was significantly associated with increasing rates of postoperative complications: RAI scores 11-15, 5.4% (n = 80); 16-20, 5.6% (n = 291); 21-25, 7.6% (n = 166); and ≥ 26, 11.6% (n = 56). The discriminatory accuracy of RAI was statistically superior (DeLong test, p < 0.05) to mFI-5 for the primary endpoints of mortality, NHD, and eLOS. All RAI C-statistics were > 0.60 for mortality within 30 days (C-statistic = 0.69, 95% CI 0.68-0.70). In a nationwide database analysis, increasing frailty, as measured by RAI, was associated with NHD, 30-day mortality, unplanned readmission, eLOS, and postoperative complications. Although the RAI outperformed the mFI-5, it is essential to account for the potentially reversible clinical issues related to the underlying disease process, as these factors may inflate frailty scores, assign undue risk, and diminish their utility. This knowledge may enhance provider understanding of the impact of frailty on postoperative outcomes for patients with iNPH, while highlighting the potential constraints associated with frailty assessment tools.

Stepwise treatment of complex intestinal fistulas and strategies of nutritional support treatment

Intestinal fistula is one of the common diseases and complications in abdominal surgery. It does not only cause severe abdominal infections but also leads to obstruction, bleeding, malnutrition, and may develop into complex intestinal fistulas, resulting in increased challenges in treatment, elevated treatment costs, and increased risk of patient mortality. At present, the treatment of intestinal fistula mainly adopts a three-stage approach: (1) early diagnosis, (2) mid-term nutritional support treatment, and (3) definitive surgical treatment. Nutritional support treatment can significantly reduce patient mortality and improve recovery. Due to the difficulty, complexity, and diversity of intestinal fistula treatment, and the fact that complex intestinal fistulas are currently a challenge in the treatment of intestinal fistulas, this article will introduce the progress and difficulties at different stages, and explore the future treatment direction of intestinal fistulas from the perspective of interdisciplinary cooperation.

Abstract 799: Area-level socioeconomic deprivation is associated with inadequate access to quality preoperative care and increased readmission after surgery for early-stage lung cancer

Abstract Objective: Socioeconomic deprivation (SED) has been associated with higher lung cancer risk and mortality. However, the effects of SED on lung cancer outcomes in an integrated, single-payer healthcare system, such as the Veterans Health Administration (VHA), remains unknown. We sought to examine the impact of area-level SED on access to care and outcomes in veterans with early-stage non-small cell lung cancer (NSCLC). Methods: We conducted a retrospective cohort study of patients with clinical stage I NSCLC receiving definitive surgical treatment in the VHA from 2006-2016. Patients were assigned an area deprivation index (ADI) score, a ZIP code-level measure of SED incorporating multiple poverty, education, housing, and employment indicators from the United States Census. Using multivariable analysis, we evaluated the relationship between ADI and guideline-concordant quality metrics (QMs) that stage I NSCLC patients should routinely meet in the preoperative (positron emission tomography [PET] imaging, smoking cessation support [SCS], pulmonary function testing [PFT], and timely surgery) and postoperative (cancer surveillance imaging, SCS, and appropriate oncology referral) periods. We also assessed the association between ADI and various cancer-specific outcomes including overall survival (OS). Results: The study included 9,704 patients. High ADI was associated with lower likelihood of receiving PET imaging (ADI ≥76 vs. ≤50: adjusted odds ratio [aOR] 0.592, 95% CI 0.502-0.698) and PFT (ADI ≥76 vs. ≤50: aOR 0.816, 95% CI 0.694-0.959) before surgery. High ADI was also associated with delayed surgery (&amp;gt;12 weeks after diagnosis; ADI ≥76 vs. ≤50: aOR 1.202, 95% CI 1.058-1.366). ADI was associated with 30-day readmission after surgery (ADI ≥76 vs. ≤50: aOR 1.380, 95% CI 1.103-1.726) but not with 30-day mortality (ADI ≥76 vs. ≤50: aOR 1.221, 95% CI 0.816-1.826), major complications (ADI ≥76 vs. ≤50: aOR 0.927, 95% CI 0.780-1.101), prolonged hospital length of stay (≥14 days; ADI ≥76 vs. ≤50: aOR 0.893, 95% CI 0.755-1.056), or 90-day mortality (ADI ≥76 vs. ≤50: aOR 0.876, 95% CI 0.645-1.190). ADI was not associated with adherence to postoperative QMs (ADI ≥76 vs. ≤50: aOR 0.888, 95% CI 0.764-1.032), OS (ADI ≥76 vs. ≤50: aOR 0.984, 95% CI 0.911-1.062), or cumulative incidence of cancer recurrence (ADI ≥76 vs. ≤50: aOR 1.047, 95% CI 0.930-1.179). Conclusions: Area-level SED is associated with inadequate adherence to preoperative QMs and increased readmission after surgery for stage I NSCLC. Our data suggests that veterans with high SED experience inadequate access to quality preoperative care for early-stage NSCLC but do not have inferior long-term outcomes after resection. Future VHA policies should focus on providing more equitable guideline-concordant preoperative care and preventing postoperative readmission for stage I NSCLC. Citation Format: Steven Tohmasi, Daniel B. Eaton, Brendan T. Heiden, Nikki E. Rossetti, Martin W. Schoen, Su-Hsin Chang, Yan Yan, Mayank R. Patel, Bryan F. Meyers, Benjamin D. Kozower, Varun Puri. Area-level socioeconomic deprivation is associated with inadequate access to quality preoperative care and increased readmission after surgery for early-stage lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 799.

Robotic Vaginal Hernia Repair for Recurrent Vaginal Prolapse Status Post-Radical Cystectomy with an Indiana Pouch.

Pelvic organ prolapse following a radical cystectomy is challenging to treat and recurrence of prolapse after primary repair is common owing to compromised pelvic floor support and tissue quality. Vaginal prolapse repairs are often preferred because of concern for patients' complex intraabdominal pathological conditions. However, for those with recurrent prolapse following colpocleisis, limited definitive treatment options exist. This surgical video presents a 64-year-old G4P4 with a history of radical cystectomy with an Indiana Pouch for invasive urothelial carcinoma who presented with recurrent stage IV vaginal prolapse two years following colpocleisis. Owing to thin vaginal tissue, a sacrocolpopexy with vaginal mesh could not be performed, thus, the patient underwent robotic-assisted vaginal hernia repair with a polypropylene-reinforced ovine tissue matrix attached to Cooper's ligament and the levator ani muscles. The surgery was free from complications and her postoperative Pelvic Organ Prolapse Quantification examination revealed a leading vaginal tissue remnant at the level of the hymen. The patient reported overall improved health and quality of life following surgery and recovery on postoperative validated questionnaires. Vaginal and pelvic floor hernia repair with a polypropylene-reinforced tissue matrix is a feasible definitive surgical treatment for patients with prior radical cystectomy in whom colpocleisis has failed.

Total Chemical Matricectomy With 88% Phenol: A Prospective Case Series of 37 Patients.

Definitive nail dystrophies, congenital, traumatic, or acquired, affecting mainly elderly patients, may not be sufficiently managed with a periodic conservative treatment. A definitive surgical treatment may be considered an alternative method, especially in symptomatic patients. To evaluate the effectiveness of total matricectomy with 88% phenol solution to treat some nail dystrophies, not otherwise satisfactorily managed. A series of 48 surgeries were performed on 37 patients. Pain evaluation, interference with shoes and gait, recurrences, and patients' satisfaction with procedure were evaluated. All patients mentioned some pain or impairment in wearing shoes before surgery. Cosmetic results were remarkable, and most of the patients (95.11%) had a dramatic improvement of their discomfort after the procedure. No severe complications occurred during the 12-month follow-up. Single-center study and the limited number of patients. Total matricectomy with 88% phenol solution is an effective surgical method with low rates of postoperative morbidity and high success rates for treating symptomatic nail dystrophies. The satisfaction with the cosmetic results is high, and this is a safe procedure for patients with associated comorbidities.

First pregnancy and live birth from ex vivo-retrieved metaphase II oocytes from a woman with bilateral ovarian carcinoma: a case report

ObjectiveTo report pregnancy and live birth resulting from intracytoplasmic sperm injection of ex vivo retrieved mature oocytes from a woman with bilateral ovarian carcinoma. DesignCase report. Subject(s)A 34-year-old nulliparous woman with bilateral ovarian tumor, with a risk of malignancy at 96.1% according to IOTA-ADNEX, who desired fertility preservation before definitive surgical treatment. Intervention(s)Cryopreservation of ex vivo retrieved mature (MII) oocytes followed by fertilization with donor sperm, and embryo transfer to a gestational carrier. Main outcome measure(s)Fertility preservation. ResultsAfter controlled ovarian stimulation, 12 MII oocytes were retrieved from oophorectomized specimens, and vitrified. ICSI with donor sperm was performed in remission, resulting in 9 cleavage-stage embryos, two of which were transferred to a gestational carrier, resulting in a normal healthy singleton pregnancy, and the live birth of a healthy baby. Conclusion(s): Ex vivo oocyte retrieval after oophorectomy may be a safe alternative to standard oocyte retrieval for fertility preservation in women with ovarian malignancies.

Improving access to pediatric hydrocephalus care for all: the role of maternal health literacy and socioeconomic status.

Limited research has addressed the barriers impeding access to surgical care for pediatric patients with hydrocephalus. To identify priorities for enhancing access to pediatric hydrocephalus surgical care and to address healthcare disparities, it is essential to understand the level of access to care and the influence of socioeconomic status (SES) and maternal health literacy. In this study, the authors aimed to assess the level of access to surgical care; determine the frequency of more than a 2-week delay in seeking, reaching, and receiving care; and investigate the influence of parental SES and maternal health literacy on these delays. This observational prospective cohort study involved data collection from a sample of 100 pediatric patients aged ≤ 5 years with hydrocephalus and their mothers, including information on family SES (education, occupational, and economic status). Maternal health literacy was assessed using the Brief Health Literacy Screen (BHLS) questionnaire. The Three Delays framework from the Lancet Commission on Global Surgery, categorizing delays in seeking care, reaching care, and definitive care, provided a structured approach for analyzing access delays. Statistical significance was set at p < 0.05. Among the pediatric patients, there was a male-to-female ratio of 1.7:1, with a median age of 1.5 months. None of the patients had insurance coverage that included surgical treatment. A significantly low number of patients accessed care within 2 weeks for seeking care duration (34%), reaching care duration (15%), and definitive care duration (1%). The median time to definitive surgical treatment for the entire study population was 14 weeks (upper SES: median 6.3 weeks, middle SES: median 9.8 weeks, lower SES: median 16.7 weeks). Through Cox proportional hazards regression, a hazard ratio of 0.046 (95% CI 0.010-0.210) was obtained. Multiple linear regression analysis identified BHLS Brief D (β = -0.335, p = 0.001) and SES (β = 0.389, p < 0.001) as predictor variables for delays in seeking care and definitive care, respectively. SES (β = 0.446, p < 0.001) and Evans index (β = 0.233, p = 0.010) were predictor variables for delays in reaching care. Maternal health literacy and SES were identified as factors associated with delays in accessing neurosurgical care for pediatric patients with hydrocephalus. To reduce disparities in pediatric hydrocephalus care, it is essential to implement strategies that promote education, improve healthcare infrastructure, and provide support to families encountering challenges related to low SES and limited maternal health literacy.