Examination Under Anesthesia Research Articles

Incidence of Steroid-Related Ocular Hypertension and Cataract Formation After Subtenon Triamcinolone in Non-Uveitic Pediatric Patients.

To describe intraocular pressure (IOP) changes after injection of subtenon triamcinolone (STT) during examination under anesthesia (EUA) for pediatric patients. Multicenter, retrospective case series of pediatric patients STT from three tertiary care ophthalmic services between November 2018 and October 2023. Of 392 patients identified, 59 eyes of 41 patients (10.5%) were included. Laser was administered in 95.1% of the cases. STT dose ranged from 4 to 20 mg. The most common diagnosis was retinopathy of prematurity (43.9%). Two eyes (3.4%) of 2 patients (4.9%) were mild steroid responders. One eye (1.7%) of 1 patient (2.4%) was a moderate responder. There were no high steroid responders, and all eyes with steroid response showed a return of IOP to normal range at next visit without needing any IOP-lowering medications. No patients were diagnosed with glaucoma or required glaucoma surgery. Only 1 eye (1.7%) developed trace posterior subcapsular cataract, while no optic disc cupping or inflammation were noted. Subtenon triamcinolone injection is commonly used to prevent inflammation at the time of retinal photocoagulation treatment in pediatric patients. It has a favorable safety profile in relation to IOP elevation and cataract formation. There was no requirement for IOP lowering medications or surgical interventions.

EP392 - Different modalities used in the investigation of anorectal lesions: a case report and discussion

Abstract Introduction Endoanal ultrasound scan (EAUS) /MRI rectum followed by early open/endoscopic, resection/biopsy for histology are important to plan management of all anorectal lesions. Here, we report an incidentally found inter-sphincteric lesion investigated with both EAUS and MRI scans, followed by excision. Case report A 55-year-old patient presented with post-menopausal bleeding and was investigated with an MRI pelvis which confirmed the causative subserosal fibroid. An incidental 15x12 mm focal soft tissue lesion at 2 o’clock between the internal and external anal canal sphincters was also picked up by the consultant GI radiologist. Her colonoscopy was normal but her digital rectal examination revealed a palpable submucosal elongated pea shaped lump at 2 o’clock. A lower GI specialist nurse performed an EAUS which suggested the lesion to be at 10 o’clock. At examination under anaesthetic (EUA), the mass in the inter-sphincter anal canal was confirmed at 2 o’clock, and excised after careful dissection from its intersphincteric location; histology confirmed a leiomyoma. The patient recovered well from the procedure. Discussion MRI and endoanal ultrasound are key imaging modalities in the diagnosis of rectal masses. EAUS provides more accurate assessment of depth of tumour invasion compared to MRI, and its relation to the anal sphincters; however, the scans are highly operator-dependent, as we found, and need to be interpreted with the benefit of clinical examination. Conclusion MRI and EAUS are complimentary in investigating rectal masses; however clinical examination, (especially under anaesthetic), as well as histology, gives the best information to plan subsequent management of common and unusual lesions (such as this) in the anorectum.

Standardization and Reproducibility of Dynamic Stress Testing for Occult Pelvic Ring Instability.

Examination under anesthesia (EUA) (stress fluoroscopy) is commonly done after pelvic ring injury to identify occult instability because unstable disruptions may displace causing morbidity. The force applied during EUA for these injuries has not been standardized. The purpose of this study was to examine the forces used during the EUA by experienced orthopaedic trauma pelvic surgeons. Orthopaedic traumatologists performed simulated EUA on a cadaver at two North American pelvis and acetabular courses using internal rotation (IR), external rotation, and push-pull maneuvers while wearing a handheld dynamometer to measure force. All surgeons used a comparable method, and each performed EUA multiple times. Maximum forces were measured in Newton (N). Eighteen surgeons participated. Four had been practicing for <5 years, six for 5 to 10 years, six for 11 to 20 years, and two for >20 years. Surgeons applied a force ranging from 40.4 to 374.9 N during IR, 72.9 to 338.4 N during external rotation, and 25 to 323 N during push-pull, with notable variability seen between surgeons. Three surgeons (18%) had >50-N variability on serial trials of a single EUA maneuver (IR). This is the first study evaluating the forces applied during pelvic EUA used to assess ring stability. Notable variability existed among surgeons performing EUA and in serial examinations by the same surgeon. Additional study is needed to standardize the displacement measured and threshold for instability that guides management.

Efficacy of a prolonged stability melphalan formulation for intra-arterial treatment of retinoblastoma

BackgroundMelphalan, which is poorly soluble at room temperature, is widely used for the treatment of retinoblastoma by selective ophthalmic artery infusion. Evomela, a propylene glycol-free formulation of melphalan with improved...

Acetabular dysplasia and posterior wall fractures: The missing link?

BackgroundTraumatologists are unable to predict hip instability based on CT scans and standard radiographs in posterior wall (PW) fractures comprising <50–60 % of the wall, necessitating an examination under anesthesia (EUA). Risk factors for instability have not been clarified, but acetabular dysplasia has been theorized as a potential etiology. Unfortunately, dysplasia is difficult to evaluate in the traumatic setting. The purpose of this study was to compare acetabular morphology between unstable and stable fractures with a novel method to detect dysplasia. MethodsPatients ≥ 18 years old with a PW fracture that underwent an EUA from 2013 to 2023 were retrospectively identified. For our experimental measurements, the axial distances on CT between the acetabular dome, lateral acetabular opening, and femoral head vertex were recorded. Acetabular geometry was quantified at these levels. Conventional dysplasia metrics (e.g., Tonnis angle) were obtained. Variables were compared between stable and unstable fractures. Results58 patients met inclusion criteria with 42 stable versus 16 unstable fractures. Unstable fractures had higher distances between the acetabular dome and femoral head vertex (p > 0.05). They had more cranial fracture exit points (p = 0.0015), lower femoral head coverage (p = 0.0102), and lower posterior acetabular sector angles (p = 0.0281). No other differences in acetabular geometry, demographics, injury characteristics, or other markers of dysplasia were identified. ConclusionsUnstable hips demonstrated a more recessed acetabular dome when compared to stable hips. Posterior acetabular femoral head coverage and cranial fracture exit point may be related to hip instability. A larger sample size is needed to validate these findings.

Abstract PO3-03-03: Prospective non-randomized study to compare accuracy of clinical examination under anesthesia, axillary ultrasound and histo-pathological evaluation for axillary nodal staging in women with clinically N0 early breast cancer

Abstract Introduction: Accurate assessment of axillary lymph nodes is crucial in the management of early breast cancer (EBC), especially in clinically node negative (cN0) axilla to avoid extensive axillary surgery. Clinical examination alone underestimates nodal disease in nearly 30% women with cN0 axilla. The current study compares, in cN0 axilla, the benefit of axillary ultrasonography (USG) and clinical axillary examination under anesthesia (EUA) to predict involvement of axillary lymph nodes. The gold standard in these patients however remains pathological evaluation after sentinel node biopsy/low axillary sampling (SNB/LAS) and a complete axillary lymph node dissection (ALND) if node positive. Methodology: Prospectively, 500 women with cN0 EBC were enrolled from Aug 2015 to April 2023 in a study approved by Institutional Ethics Committee. After informed consenting, a preoperative axillary USG was carried out in addition to standard breast imaging to determine number of axillary node(s) and its architecture. The USG assessment was labeled as suspicious or not and the result was blinded to the surgeons. A USG-guided FNAC was not performed as it would then be difficult to blind the surgeon and pathologist preoperatively. During surgery, an initial axillary EUA was performed before starting and any suspicious node was documented. This was followed by axillary staging by standard dual tracer SNB/LAS. A complete axillary dissection was done (level 1-3) if any node was positive on frozen section evaluation or final histopathology. Axillary node histopathology was the gold standard for comparison of effectiveness of clinical exam, USG, EUA, and SNB/LAS for prediction of axilla. Standard diagnostic tests such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were used. Results: Thirty-six patients were excluded in the final analysis (disease progression, chemotherapy first, or had a surgery elsewhere). Of the eligible 464 cN0 patients, 129 were detected to have axillary metastases (27.8%) in final histopathology. The 2 interventions namely USG axilla, EUA were compared to final axillary nodal histopathology. Axillary USG reported suspicious/indeterminate node(s) in 129 (27.8%) patients. USG had a low sensitivity of 46.5% and a low PPV of 46.5% to identify a positive node. However, the specificity and NPV both were 79.4%. Axillary USG was 70.2% accurate in predicting axillary nodal involvement. EUA also had sensitivity of 60% and low PPV of 14.8%. However, the specificity of EUA was 73.4%, NPV of 95.9%; higher than that of USG. EUA was 72.4% accurate. SNB/LAS had the sensitivity of 93.3%, specificity 79.2%, NPV 82.9%, PPV 91.6% and accuracy rate 89.2% in predicting a positive axilla. Conclusions: While the fallacy of clinical exam remains at 27.8%, both USG alone (without FNAC) and EUA failed in predicting a positive axillary node. EUA fared better at predicting a negative axilla. USG guided FNAC would perhaps improve the sensitivity of USG, however additional investigations are difficult in resource constraint and high-volume center, especially, when surgical interventions like SNB or LAS remain standard of care. Table 1 Citation Format: Vani Parmar, Zeal Sanghvi, Shalaka Joshi, Nita Nair, Palak Popat, Seema Kembhavi, Souwmyashree KN, Soujanya Mynalli, Purvi Thakkar, Garvit Chitkara, Sangeeta Desai, Tanuja Shet, Rajendra Badwe. Prospective non-randomized study to compare accuracy of clinical examination under anesthesia, axillary ultrasound and histo-pathological evaluation for axillary nodal staging in women with clinically N0 early breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-03.

Snapping Biceps Femoris Repair: A Rare Cause of Lateral Knee Pain

Background: Snapping biceps femoris syndrome (SFS) represents a rare clinical entity in which the biceps femoris subluxates over the fibular head in deep flexion. Two primary pathophysiologies have been described including a prominent or abnormal fibular head morphology. Others have implicated an anomalous biceps femoris insertion. The diagnosis is made clinically, with operative and nonoperative intervention strategies available for treatment. Indications: SFS often results in audible snapping and associated pain at the lateral fibular head. When recalcitrant to nonoperative management, surgical intervention can lead to resolution of symptoms. We present the case of a college-aged male who has bilateral symptoms, worse on the right, which have resulted in significant activity modification and daily discomfort recalcitrant to anti-inflammatory medication and physical therapy. Technique Description: The patient was placed supine on the operating room table with an ipsilateral bump under the hip to assist in exposure of the lateral aspect of the knee. Examination under anesthesia (EUA) confirmed the snapping biceps femoris. A lateral approach to the knee and a common peroneal neurolysis was performed. The biceps femoris insertional anatomy was examined for anomalous tendon insertion or insertional tearing. The prominent fibular head was exposed and resected, with careful attention not to disrupt the lateral collateral ligament or popliteofibular ligament insertion sites. The biceps femoris was then repaired to the prepared bony bed of the fibula with one double-loaded suture anchor. Repeat EUA confirmed complete resolution of snapping even with maximal internal rotation of the tibia; this was carefully examined again with the tourniquet deflated to ensure its compressive effect was not partially responsible for the resolution. Results: Published data pertaining to SFS is limited to case reports and small case series. With appropriate indications, surgical intervention yields promising results with a high percentage of patients returning to prior level of activity or prior participation level in sport. Discussion/Conclusion: SFS can be diagnosed with a careful clinical assessment. When recalcitrant to nonoperative management, it is effectively treated with surgical intervention to restore normal fibular anatomy, and prevent recurrent instability and persistent pain. The presented technique allows for appropriate management of these rare injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Role of multi-parametric magnetic resonance imaging in preoperative staging of cervical carcinoma in females

BackgroundIn cervical cancer, accurate diagnosis of parametrial invasion (PMI) helps in determining the next step in management, either surgical resection or neoadjuvant therapy. Cervical cancer staging is still determined according to the clinical findings. But it is widely recognized that there are differences between clinical evaluation and the actual disease extent, particularly for PMI. In this prospective study, we investigate the relationship between clinical staging and magnetic resonance imaging (MRI) staging with post-management findings among patients with cervical cancer who underwent pre-treatment MRI, using fused T2-weighted image/diffusion-weighted imaging (T2/DWI).ResultsBased on examination under anesthesia (EUA), 80% of patients showed PMI, while fused T2/DWI was positive for PMI in 77.5% of patients. In all analyzed cases (40 females), MRI had sensitivity, specificity, and accuracy of 91%, 75%, and 87.5% compared to EUA. In the operated patients (24 females), MRI likewise had sensitivity, specificity, and accuracy of 81.3%, 87.5%, and 83%, respectively. In comparison with the postoperative results, the EUA showed higher sensitivity and accuracy than MRI (92.9% vs. 81.3%) and (83.3% vs. 79.2%), respectively, in the detection of PMI in operated cases. However, MRI was more specific in the PMI detection in cases with cervical cancer than EUA (75% vs. 70%).ConclusionMRI (with the aid of fused T2/DWI) improves the diagnostic performance for the PMI assessment in cases with cervical carcinoma. Therefore, MRI is helpful in choosing surgical candidates.

The assessment of bladder cancer resectability with bimanual palpation: A prospective study in laparoscopy and open cystectomy patients

PurposeTo evaluate the value of examination under anesthesia (EUA) in the assessment of bladder resectability during cystectomy. Materials and methodsThis prospective study included consecutive patients undergoing cystectomy for bladder cancer at a single center between June 2017 and October 2020. EUA was conducted before cystectomy by two urologists who assessed the bladder for limited mobility. One examiner was blinded to the imaging results. Soft tissue surgical margin status in the pathological evaluation of a cystectomy specimen served as a measure of resectability. We used multivariable logistic regression models to assess whether EUA performed by blinded or non-blinded examiners is associated with soft tissue positive surgical margins (PSMs) and to calculate the fraction of new information added by such an examination in addition to selected clinical variables. ResultsAmong the 134 patients analyzed, limited bladder mobility was indicated by the blinded and non-blinded examiners in 23 (17.2%) and 21 (15.7%) cases, respectively. PSMs were identified in 22 (16.4%) patients, more often in patients with limited bladder mobility as assessed by the blinded (odds ratio [OR] 6.7; 95% confidence interval [CI], 1.9–24.2) and non-blinded examiners (OR 12.9; 95% CI, 2.9–57.5). The fraction of new information added by the blinded and non-blinded examiners was 48.6% and 57.7%, respectively.The enrichment of patients who underwent pure laparoscopic cystectomy (n = 102; 76%) and the inclusion of patients for emergent surgery may limit the generalizability of our findings. ConclusionsThe identification of limited bladder mobility during preoperative EUA yielded prognostic information on surgical margin status. Our findings suggest that EUA has the potential to provide valuable insights in the assessment of bladder resectability. However, further research in a larger cohort of patients is warranted to validate and expand on these findings.

A New Computed Tomography-Based Measure that Provides Insight Into Hip Stability in Patients With Posterior Wall Acetabular Fractures.

To describe the technique and results of a new sagittal plane computed tomography (CT)-based angular measure for predicting stability after posterior wall acetabular fractures (PWF). Retrospective review. Academic Level II trauma center. Fifty-eight consecutive patients with PWF (AO/OTA class 62A.1), 98% were high-energy injuries. A new sagittal CT measure of PWF based on the angle subtending the joint center, cranial and caudal fracture exits. Hip incongruity or dislocation demonstrated using gold standard test, examination under anesthesia (EUA), or instability on static images. Prediction of hip instability using a sagittal CT angular measure based on cranial and caudal fracture exits was compared with previous axial CT measures suggestive of increased risk for instability including posterior wall size >50%, and those with cranial exit within 5.0 mm of the acetabular dome. There were 32 operative and 26 nonoperatively treated fractures. Thirty fractures were determined to be unstable, and 28 were stable after EUA. Measurements of >70 degrees using the sagittal CT angular measure predicted instability in 28 of 28 patients, and ≤70 degrees predicted stability in 30 of 30 patients (sensitivity 100% and specificity 100%). Prevalence of EUA confirmed instability for subgroups with PWF based on prior axial CT measures were as follows: ≥50% wall involvement (11/16; sensitivity 67% and specificity 60%; 95% CI, 45%-89%/45%-75%), fracture within 5.0 mm of dome (5/18; sensitivity 86% and specificity 73%; 95% CI, 71%-100%/59%-87%), fracture within 5.0 mm of dome and ≥50% involvement (1/9; sensitivity 89% and specificity 56%; 95% CI, 69%-100%/24%-88%). In a sample of 58 mostly high energy posterior wall fractures all having had an EUA, a new sagittal angular CT measurement of ≤70 degrees predicted hip stability and >70 degrees predicted instability with 100% sensitivity and specificity. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Correlation of anterior segment optical coherence tomography and ultrasound biomicroscopy in congenital corneal opacity

To investigate the correlation between swept-source anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) in congenital corneal opacity (CCO). All children with unilateral or bilateral congenital corneal opacities who underwent examination under anesthesia (EUA) and anterior segment optical coherence tomography (AS-OCT) imaging from January 1, 2022, to December 31, 2022, were included. Main outcome measures were corneal and anterior segment evaluation and correlation of UBM and AS-OCT findings. A total of 22 eyes of 15 patients were imaged using both technologies. The age at first EUA ranged from 11 days to 4 years. Different phenotypes were classified based on the clinical examination, UBM, and AS-OCT findings. Fourteen eyes were diagnosed with Peters anomaly, congenital corneal staphyloma was observed in 4 eyes, 2 eyes had coloboma, 1 eye had peripheral sclerocornea, and 1 eye was diagnosed with congenital primary aphakia. AS-OCT and UBM findings were closely correlated in 18 of 22 eyes (82%) but AS-OCT failed to provide detailed information in 4 eyes (18%) where UBM revealed more details. Although AS-OCT offers valuable preliminary data for initial assessment and counseling, it may not consistently provide precise assessments in all cases. Therefore, UBM should be considered for definitive evaluation.

P736 Class 4 Fistulizing Perineal Disease after Proctectomy for Crohn’s Disease: A Multicentre Study

Abstract Background The TOpCLASS International Consortium recently described a paradigm shifting classification scheme for perianal Crohn’s disease, based on the desired patient goals of care. Class 4 perineal fistulizing disease is a CD that persists after proctectomy, and there are limited data defining this entity. We sought to determine the rates of clinical perineal fistulizing disease after proctectomy and to secondarily define the risk factors for recurrence. Methods Adult patients with CD who underwent perineal resection with proctectomy or proctocolectomy at three hospitals within our institution’s health network between 2009 and 2021 were retrospectively reviewed. The exclusion criteria included a preoperative diagnosis of ulcerative colitis or indeterminate colitis, and patients who underwent restorative proctectomy. Extracted data included baseline demographic data, preoperative medical treatment for CD, proctectomy indication, clinical recurrence of perineal disease, and resolution of perineal disease. Results A total of 405 patients with Crohn’s disease were included, including 190 (46.9%) who underwent proctectomy and 215 (53.1%) who underwent proctocolectomy. The median age was 44 years (IQR 33-58) and 58.8% of the patients were female. Within three months prior to surgery, 36% were exposed to biologic therapy, 29.1% to immunomodulators, and 11.4% to corticosteroids. During a median follow-up of 4 years, clinical recurrence of fistulizing perineal CD occurred in 62 (15.3%) patients, including five patients with perineal-vaginal fistulas and one with adenocarcinoma in the fistula tract. The median time to the development of perineal disease was 6.5 months (IQR 3-23 months). Factors associated with perineal disease included younger age (38 vs. 46 years; p &amp;lt;0.01), female sex (71% female vs. 56.6% female; p=0.03), preoperative corticosteroid use (19.4% vs. 9.9%; p=0.031), and the presence of perianal CD, regardless of the indication for proctectomy (85.4% vs 60.1%; p&amp;lt;0.01). After treatment for class 4 disease, perineal symptom resolution was observed in 40 (62.9%) patients. There were 79 (19.5%) patients underwent examination under anesthesia (EUA) for perineal disease, with a median of 2 EUA’s (range 1-21). Preoperative biological therapy was not associated with recurrent perineal disease (p= 0.29). Conclusion Perineal CD after proctectomy is common and frequently requires multiple surgical interventions. Younger age, female sex, preoperative corticosteroid use, and the presence of perianal disease may benefit from a more intensive postoperative review and consideration of the continuation or early initiation of prophylactic post-proctectomy CD medical management with biologics.

CHOROIDAL OSTEOMA IN AN INFANT

Purpose: To describe a case of choroidal osteoma with macular involvement in an infant that was treated with transpupillary thermotherapy. Methods: A case report. Results: An 11-month-old infant presented for retinopathy of prematurity follow up examination and was found to have a three disc-diameter round, orange, subretinal, slightly elevated lesion with well-defined margins in the superior macula of the left eye. B-scan ultrasonography showed a slightly elevated, highly reflective choroidal mass with acoustic shadowing. A diagnosis of choroidal osteoma was made. Six months later, repeat examination under anesthesia (EUA) showed the lesion to be increasing in size and encroaching on the fovea. Given demonstrated growth and the risk of central vision loss, the patient was treated with transpupillary thermotherapy (TTT). Subsequent EUAs, over a period of four months, have shown complete decalcification with no subsequent growth. Conclusion: Choroidal osteomas are benign lesions that can be sight threatening if located in the macula. TTT in this case resulted in complete regression of a sight threatening extrafoveal choroidal osteoma at four month follow up.

Diagnostic accuracy of MRI for detection of occult instability of type I anterior to posterior pelvic injuries

Type I Young and Burgess anterior posterior compression (APC) pelvic injuries have been classically managed non operatively due to theoretical integrity of sacroiliac joint ligaments (SIJL), though examination under anesthesia (EUA) has been proven occult mechanical instability in up to 50% of these injuries. We sought to determine the diagnostic accuracy of magnetic resonance (MRI) for detection of occult instability on APC-I injuries when compared to EUA.Methods: Diagnostic test study of prospectively recruited patients admitted with APC-I pelvic injuries between 2015 and 2022. All patients consented to participate in this study were subjected to MRI and EUA. The evaluators of each of these tests were blinded. On MRI evaluation, SIJL were considered compromised when unilateral injury to anterior SIJL was visualized in three or more consecutive images or in bilateral injuries, when injury to the anterior SIJL in two or more consecutive images on each side was observed. Positive EUA was considered a symphyseal diastasis over 25 mm on stress fluoroscopy. Demographic data was collected as recruited and sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. Confidence interval was set at 95%. EUA was considered the gold standard in statistical analysis.Results: A total of 32 patients mean aged 36 (24–61) years were included. Mean symphyseal diastasis at admission was 17.58 (11 - 25) mm. The median time from injury to EUA was 5 (0–21) days. Positive EUA was observed on 20 patients and 25 patients presented compromised SIJL. MRI presented a sensitivity of 95% (75.13% - 99.87%), specificity of 50% (21.09% - 78.91%), positive-predictive value of 73% (60.61% to 82.93%), negative-predictive value of 87% (48.66% - 98.08%).Conclusion: Injury to SIJL on MRI presented an accuracy of 77% (58.29% - 89.64%) for the detection of occult pelvic instability on EUA.

Pelvic examination under anesthesia by learners at the time of abortion: Who accepts and who declines?

ObjectivesThis study aimed to assess the prevalence of and factors correlated with accepting a pelvic examination under anesthesia (EUA) by learners at the time of surgical abortion. Study designRetrospective chart review assessing the prevalence of and comparing factors associated with accepting EUA by learners at the time of abortion. ResultsMost (88%) of the 274 patients accepted EUA by learners. Declining was associated with prior intimate partner violence. ConclusionsMost patients accept EUA by learners at the time of abortion. ImplicationsIn adhering to fundamental principles of medical ethics, professional guidelines, and legal mandates, consent prior to pelvic EUA by learners should be obtained universally.

Diagnostic accuracy of bimanual palpation in bladder cancer patients undergoing cystectomy: A prospective study.

To prospectively assess the concordance of examination under anesthesia (EUA)-based clinical T stage with pathological T stage and diagnostic accuracy of EUA in patients with bladder cancer undergoing cystectomy. Consecutive patients with bladder cancer undergoing cystectomy between June 2017 and October 2020 in a single academic center were included in a prospective study. Two urologists performed EUA (one blinded to imaging) before patients underwent cystectomy. We assessed the concordance between clinical T stage in bimanual palpation (index test) and pathological T stage in cystectomy specimens (reference test). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated with 95% confidence intervals (CIs) to detect or exclude locally advanced bladder cancer (pT3b-T4b) in EUA. The data of 134 patients were analyzed. Given that stage pT3a cannot be palpated, for the nonblinded examiner, T staging in EUA was concordant with pT in 107 (79.9%) patients, 20 (14.9%) cases being understaged in EUA and 7 (5.2%) overstaged. For the blinded examiner, staging was correct in 106 (79.1%) patients, 20 (14.9%) cases being understaged and 8 (6%) overstaged. For the nonblinded examiner, sensitivity, specificity, PPV, and NPV of EUA were 55.9% (95% CI 39.2%-72.6%), 93% (88%-98%), 73.1% (56%-90.1%), and 86.1% (79.6%-92.6%), respectively; for the blinded examiner, they were 52.9% (36.2%-69.7%), 93% (88%-98%), 72% (54.4%-89.6%) and 85.3% (78.7%-92%), respectively. Awareness of imaging results did not have a major impact on EUA results. Bimanual palpation should still be used for clinical staging, given its specificity, NPV, and that it could correctly determine bladder cancer T stage in 80% of cases.

Crohn’s disease-related anal fistula cancer diagnosed by examination under anesthesia: a case report

BackgroundAs the number of patients with inflammatory bowel disease (IBD) increases, the incidence of IBD-related colorectal cancer (CRC) is also on the rise. Crohn’s disease (CD)-related CRC has been reported to have a poorer prognosis than sporadic CRC, and the early detection of CD-related CRC is difficult. Japanese patients with CD are reported to have a higher frequency of anorectal cancer than the Western population; however, methods for early diagnosis have not yet been established because of perianal pain during the examination.Case presentationWe report a case of CD-related anal fistula cancer that was detected early by surveillance examination under anesthesia (EUA). The patient was a 37-year-old man, diagnosed with CD at the age of 15 years and started medical treatment. However, due to poor disease control, the intestinal tract remained highly inflamed and the patient continued to have over 10 bowel movements per day. He was referred to our hospital for surgical treatment after a colonoscopy (CS), which revealed multiple active ulcers and stenoses. Since three perianal seton drainage tubes had been placed around his anus since the age of 33 years, we decided to perform an EUA to rule out cancer coexistence in the anorectal region. After a random biopsy of the rectum by CS under general anesthesia, we resected and curetted multiple perianal fistulas as much as possible and reinserted the seton drainage tubes. Pathological examination of the fistula tract revealed adenocarcinoma in one tract, indicating the coexistence of anal fistula cancer. Based on the diagnosis of multiple intestinal stenoses and anal fistula cancer due to CD, we performed hand-assisted laparoscopic total colectomy, rectal amputation, extensive perineal resection, and reconstruction using a left rectus abdominis flap.ConclusionIn a long-term CD patient with anorectal lesions, we performed an EUA to diagnose the coexistence of anal fistula cancer at an early stage, and surgical resection was achieved. EUA is effective for the early detection and treatment of CD-related CRC and may contribute to an improved prognosis.

FTP2.5 Clinical audit following initial experience from a dedicated botox clinic for the treatment of anal fissure

Abstract Background and Aims Chronic anal fissure is a common and debilitating disease. Intersphincteric injection of Botulinum Toxin A during examination under anaesthesia (EUA) is an established treatment option following failed conservative management. The aim of this study was to investigate the effectiveness of clinic-based Botox injection for treatment of chronic anal fissure as an alternative to injection under anaesthesia. Feasibility was evaluated in terms of cost, safety and sustainability. Methods This was a retrospective single centre study of prospectively collected data between August 2021 and August 2022. Demographic data, treatment protocols and follow-up outcomes at three months were collated. The relative costs were provided by the regional financial department. Results Sixty-four patients were referred to clinic in the first year. Anal fissure was confirmed in 63% of patients with 89% receiving Botox injection in the clinic setting with no major complications. Healed fissure was induced in 85% of patients reviewed at a three-month follow-up. Five patients required referral for EUA with injection of botox. An estimated cost saving of £1,308.50 per case was achieved for clinic-based Botox versus Botox administered via EUA. Clinic-based administration of Botox reduced theatre resource utilisation during the study period. Conclusion Clinic-based Botox administration is feasible, safe and effective in the treatment of chronic anal fissure. This treatment approach not only provides a clinically effective, cost-efficient alternative to surgery but reduces resource utilisation and waste which is environmentally beneficial.

Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement.

Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries. Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5mm. As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0mm, CI: -4.8 to -1.6mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively). Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively. Level III, prognostic retrospective cohort study.

Does sequential examination under anaesthesia provide a reliable method to determine a management plan for unstable lateral compression pelvic ring injuries? a prospective study.

To assess the reliability of sequential examination under anaesthesia (EUA) to determine pelvic instability and to evaluate radiological and functional outcomes in unstable lateral compression (LC) injuries. A prospective case series study was conducted from 2020 to 2022 at a university hospital on 43 cases with LC injuries that met the inclusion criteria. Sequential EUA was carried out in three steps. Posterior-only fixation or anterior-posterior fixation was done according to the algorithm. Each patient was followed up for at least 12months, both radiologically and functionally. Forty cases proved unstable and were fixed. None showed secondary displacement in the anterior-posterior fixation group. However, five cases (19.2%) of the posterior-only fixation group showed secondary displacement with a mean of 5.9mm. Four cases of them had tetra-ramic injuries. There is a high tendency for secondary displacement at 14.5mm or more preoperative displacement of the rami. Patients with secondary displacement showed comparable functional outcome scores to patients without secondary displacement. Posterior-only fixation showed shorter operative time, lesser radiological exposure, blood loss and iatrogenic nerve injury than anterior-posterior fixation. EUA is a reliable method to determine pelvic instability and management plan for LC fractures with unilateral anterior ring injury. Anterior-posterior fixation is needed if there is a tetra-ramic fracture or initial anterior ring displacement of 14.5mm or more, irrespective of EUA.