Excellent Symptomatic Relief Research Articles

7008 Challenges in the Management of Thyroid Lymphoma - Case Report

Abstract Disclosure: F. Toloza Bonilla: None. P. Veeraraghavan: None. R. Lakhotia: None. M. Roschewski: None. N. Nilubol: None. S. Gubbi: None. J. Klubo-Gwiezdzinska: None. Introduction: Primary thyroid lymphoma is an extremely rare thyroid malignancy accounting for less than 5% thyroid malignancies. The management depends on the histological subtype and tumor staging, typically involving chemotherapy alone or combined with radiotherapy. Although, surgical intervention is generally not recommended, given the potential surgical risks and the absence of additional benefits compared to chemoradiation therapy, it is reserved to obtain tissue diagnosis and to treat compressive symptoms. Clinical Case: A 66-year-old Caucasian female presented with dysphagia to solid food and acute neck swelling for a few weeks. History was negative for fever, weight loss or nocturnal diaphoresis. The patient had a history of primary hypertension, pre-diabetes, and Hashimoto’s hypothyroidism. A neck computed tomography (CT) scan showed a thyromegaly (8.3 x 5.8 cm) and bilateral cervical lymphadenopathy. Thyroid ultrasound showed sub centimeter nodules in the right mid-gland and a heterogeneous and irregular left thyroid lobe. TSH was normal (0.87 mcIU/mL [0.27-4.2]). She was treated for suspected subacute thyroiditis with prednisone for two weeks, showing initial clinical improvement, but symptoms recurred after steroids were stopped. Subsequently, a CT neck and fludeoxyglucose F18 (FDG) positron emission tomography (PET) scan demonstrated FDG avid thyroid enlargement with local adenopathy and rightward tracheal deviation. Lymph node, FNA, core biopsies and molecular testing were consistent with stage IIE MYC/BCL6 rearranged diffuse large B-cell lymphoma as she had no bone marrow or central nervous system (CNS) involvement. The patient’s treatments included four cycles of etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab with ibrutinib added after the first cycle and intrathecal methotrexate with cycles 3-6, to reduce the risk of CNS involvement. A 6-month post-therapy follow-up showed complete response (CR) on imaging with symptoms resolution. Four months later, she experienced worsening symptoms, including dysphagia with solids and liquids, and hoarseness despite CR to therapy and stable CT imaging. Laryngoscopic evaluation noted left vocal cord paralysis and extrinsic compression of the tracheoesophageal groove. Patient opted for a left hemithyroidectomy, experiencing excellent symptom relief. Surgical pathology showed findings consistent with a necrotic tumor and residual areas of lymphocytic thyroiditis. No active DLBCL was appreciated. The patient remains in remission and continues to be symptoms-free 24 months post-thyroid lymphoma treatment. Conclusion: While thyroidectomy is not typically recommended as the initial treatment for primary thyroid lymphoma, it emerges as a potentially effective option to manage recurrent or persistent compression symptoms following the completion of medical therapy. Presentation: 6/3/2024

Analysis of completion intraoperative venography during first rib resection for venous thoracic outlet syndrome

BackgroundWe evaluated the impact of completion intraoperative venography on clinical outcomes for axillosubclavian vein (AxSCV) thrombosis owing to venous thoracic outlet syndrome (vTOS). MethodsWe performed a retrospective, single-center review of all patients with vTOS treated with first rib resection (FRR) and intraoperative venography from 2011 to 2023. We reviewed intraoperative venographic films to classify findings and collected demographics, clinical and perioperative variables, and clinical outcomes. Primary end points were symptomatic relief and primary patency at 3 months and 1 year. Secondary end points were time free from symptoms, reintervention rate, perioperative complications, and mortality. ResultsFifty-one AxSCVs (49 patients; mean age, 31.3 ± 12.6 years; 52.9% female) were treated for vTOS with FRR and external venolysis followed by completion intraoperative venography with a mean follow up of 15.5 ± 13.5 months. Before FRR, 32 underwent catheter-directed thrombolysis (62.7%). Completion intraoperative venography identified 16 patients with no stenosis (group 1, 31.3%), 17 with no stenosis after angioplasty (group 2, 33.3%), 10 with residual stenosis after angioplasty (group 3, 19.7%), and 8 with complete occlusion (group 4, 15.7%). The overall symptomatic relief was 44 of 51 (86.3%) and did not differ between venographic classifications (group 1, 14 of 16; group 2, 13 of 17; group 3, 10 of 10; and group 4, 7 of 8; log-rank test, P = .5). The overall 3-month and 1-year primary patency was 42 of 43 (97.7%) and 32 of 33 (97.0%), respectively (group 1, 16 of 16 and 9 of 9; group 2, 16 of 17 and 12 of 13; group 3, 10 of 10, 5 of 5; group 4, primary patency not obtained). There was one asymptomatic rethrombosis that resolved with anticoagulation, and three patients underwent reintervention with venous angioplasty for significant symptom recurrence an average 2.89 ± 1.7 months after FRR. ConclusionsOur single-center retrospective study demonstrates that FRR with completion intraoperative venography has excellent symptomatic relief and short- and mid-term patency despite residual venous stenosis and complete occlusion. Although completion intraoperative venographic classification did not correlate with adverse outcomes, this protocol yielded excellent results and provides important clinical data for postoperative management. Our results also support a conservative approach to AxSCV occlusion identified after FRR.

OGBN P29 Short term outcomes after anti-reflux surgery for Gastro-Oesophageal Reflux disease

Abstract Background Laparoscopic fundoplication is the standard surgical practice for management of Gastro-oesophageal reflux Disease (GORD). However, post operative complications and recurrence can be problematic. We conducted this study to assess short-term post operative outcomes following anti-reflux surgery (ARS) for GORD at our UGI surgery unit at a busy District General Hospital (DGH). Methods All patients above 18 years of age undergoing ARS between January 2016 and December 2021 were included. We excluded patients who underwent fundoplication as part of treatment of achalasia or large hiatus hernia repairs. Data was collected retrospectively from a prospectively maintained database. Pre –operative investigations and surgical procedure was recorded. Primary outcome assessed were post-operative complications recorded as per Clavien-Dindo grade and re-operation rates. Secondary outcomes assessed were symptomatic relief and proton pump inhibitor (PPI) discontinuation. Results 86 patients were included. The median age at surgery was 52 years. 98% patients had typical symptoms of GORD at presentation. On pre-operative OGD, 29% patients had oesophagitis and 77.91% had hiatus hernia. 79 (91.86%) patients underwent pH manometry. 97.67% patients underwent Nissen fundoplication. All cases were successfully completed laparoscopically with no conversions to open. The median post-operative length of stay was 1 day. 93.02% had no post operative complications, and none had 30 day re-operation. At 1-year follow up, 97.67% patients reported improvement in symptoms and 94.19% patients were able to stop PPI use. Conclusions Laparoscopic fundoplication provides excellent relief of GORD symptoms with low incidence of post operative complications and re-operation rates.

Comparison of outcomes following polidocanol microfoam and radiofrequency ablation of incompetent thigh great and accessory saphenous veins

BackgroundMicrofoam ablation (MFA) and radiofrequency ablation (RFA) are both approved by the Food and Drug Administration for treatment of proximal saphenous truncal veins. The objective of our study was to compare early postoperative outcomes between MFA and RFA following treatment of incompetent thigh saphenous veins. MethodsA retrospective review of a prospectively maintained database was conducted of patients who underwent treatment of incompetent great saphenous veins (GSVs) or anterior accessory saphenous veins (AASVs) in the thigh. All the patients underwent duplex ultrasound of the treated leg at 48 to 72 hours postoperatively. Patients were excluded from analysis if concomitant stab phlebectomy was performed. Demographic data, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, venous clinical severity score (VCSS), and adverse events were recorded. ResultsBetween June 2018 and September 2022, 784 consecutive limbs (RFA, n = 560; MFA, n = 224) underwent venous closure for symptomatic reflux. A total of 200 consecutive thigh GSVs and ASVs treated within the study period using either MFA (n = 100) or RFA (n = 100) were identified. The patients were predominantly women (69%) with a mean age of 64 years. The preoperative CEAP classification was similar between the MFA and RFA groups. The mean preoperative VCSS was 9.4 ± 2.6 for the RFA patients and 9.9 ± 3.3 for the MFA patients. Among the RFA patients, the GSV was treated in 98% and the AASV in 2% compared with the GSV in 83% and the AASV in 17% in the MFA group (P < .001). The mean operative time was 42.4 ± 15.4 minutes in the RFA group and 33.8 ±16.9 minutes in the MFA group (P < .001). The median follow-up was 64 days for the study cohort. The mean postoperative VCSS declined to 7.3 ± 2.1 in the RFA group and 7.8 ± 2.9 in the MFA group. Complete closure occurred in 100% of the limbs after RFA and 90% after MFA (P = .005). Eight veins were partially closed and two remained patent following MFA. The incidence of superficial phlebitis was 6% and 15% (P = .06) after RFA and MFA, respectively. Overall, symptomatic relief was 90% following RFA and 89.5% following MFA. The complete ulcer healing rate for the entire cohort was 77.8%. Deep venous proximal thrombus extension (RFA, 1%; vs MFA, 4%; P = .37) and remote deep vein thrombosis (RFA, 0%; vs MFA, 2%; P = .5) showed a trend toward being higher following MFA but the difference did not reach statistical significance. All were asymptomatic and resolved with short-term anticoagulation therapy. ConclusionsMFA and RFA are both safe and effective for treating incompetent thigh saphenous veins, with excellent symptomatic relief and a low incidence of postprocedure adverse thrombotic events. RFA resulted in improved complete closure rates following initial treatment compared with MFA. The operative times were shorter with MFA. Both modalities can be used for patients with active venous ulcers with good healing rates. Longer term studies are required to characterize the durability of MFA closure for above knee truncal veins.

Characterization and surgical management of aberrant subclavian arteries

ObjectiveAberrant subclavian arteries (aSCAs), with or without aortic pathology, are uncommon. The purpose of the present study was to review our experience with the surgical management of aSCA. MethodsWe performed a retrospective review of patients who had undergone surgery for an aSCA between 1996 and 2020. Symptomatic and asymptomatic patients were included. The primary end points were ≤30-day and late mortality. The secondary end points were ≤30-day complications, graft patency, and reinterventions. ResultsA total of 46 symptomatic and 3 asymptomatic patients with aSCA had undergone surgery (31 females [62%]; median age, 45 years). An aberrant right subclavian artery was present in 38 (78%) and an aberrant left subclavian artery in 11 patients (22%). Of the 49 patients, 41 (84%) had had a Kommerell diverticulum (KD) and 11 (22%) had had a concomitant distal arch or proximal descending thoracic aortic aneurysm. Symptoms included dysphagia (56%), dyspnea (27%), odynophagia (20%), and upper extremity exertional fatigue (16%). Five patients (10%) had required emergency surgery. The aSCA had been treated by transposition in 32, a carotid to subclavian bypass in 11, and an ascending aorta to subclavian bypass in 6. The KD was treated by resection and oversewing in 19 patients (39%). Fifteen patients (31%) had required distal arch or proximal descending thoracic aortic replacement for concomitant aortic disease and/or KD treatment. Thoracic endovascular aortic repair was used to exclude the KD in six patients (12%). Seven patients (14%) had undergone only bypass or transposition. The 30-day complications included one death from pulseless electrical activity arrest secondary to massive pulmonary embolism. The 30-day major complications (14%) included acute respiratory failure in three, early mortality in one, stroke in one, non–ST-elevation myocardial infarction in one, and temporary dialysis in one patient. The other complications included chylothorax/lymphocele (n = 5; 10%), acute kidney injury (n = 2; 4%), pneumonia (n = 2; 4%), wound infection (n = 2; 4%), atrial fibrillation (n = 2; 4%), Horner syndrome (n = 2; 4%), lower extremity acute limb ischemia (n = 1; 2%), and left recurrent laryngeal nerve injury (n = 1; 2%). At a median follow-up of 53 months (range, 1-230 months), 40 patients (82%) had had complete symptom relief and 9 (18%) had experienced improvement. Six patients had died at a median of 157 months; the deaths were not procedure or aortic related. The primary patency was 98%. Reintervention at ≤30 days had been required for two patients (4%) for ligation of lymphatic vessels and bilateral lower extremity fasciotomy after proximal descending thoracic aorta replacement. One patient had required late explantation of an infected and occluded carotid to subclavian bypass graft, which was treated by cryopreserved allograft replacement. ConclusionsSurgical treatment of the aSCA can be accomplished with low major morbidity and mortality with excellent primary patency and symptom relief.

The Effectiveness of PAlliative Split COurse RAdiotherapy (PASCORA) Regimen in Non-metastatic Head and Neck Cancer Patients who are Treated with Palliative Intent- A Retrospective Single Centre Study

Introduction: We at our centre practice a PAlliative Split COurse RAdiotherapy (PASCORA) of 22.5Gy in 5 fractions followed by a gap of 4 weeks and then again repeat 22.5Gy in 5 fractions for locally advanced squamous cell carcinoma patients treated with a palliative intent. Aim was t0 assess the symptomatic relief at 3 months following PASCORA regimen. Materials &amp; Methods: 49 Patients with LAHNSCC between January 2014 to January 2021, planned for PASCORA regimen were evaluated. Symptomatic relief was assessed on an objective scale. OS was determined using Kaplan Meir survival curves. Results: Median age was 61 years, multiple comorbidities (37%) were the most commonly documented reason for these patients being treated with a palliative intent. 25% of our patients had an excellent symptomatic relief, 26% of our patients had a good symptomatic relief and 31% had a partial relief. Median OS was 38 months in patients who had an excellent symptomatic relief and 3-8 months in patients with no or partial symptomatic relief ( p value=0.000) 6% of our patients had Grade 3 /4 RTOG toxicity. Conclusion: PASCORA regimen offers a good symptomatic relief with good local control rates and acceptable level of toxicity and comparable OS.

Interventions for superior vena cava syndrome.

Superior vena cava (SVC) syndrome refers to the clinical manifestations of cerebral venous hypertension secondary to obstruction of the SVC and/or the innominate veins. The most common cause of SVC syndrome is malignancy like small cell lung cancer and non-Hodgkin lymphoma, but there is an increasing trend of benign etiologies secondary to thrombosis due to central lines/ pacemakers or mediastinal fibrosis. Supportive measures include head elevation, diuresis, supplemental oxygen, and steroids. Thrombolysis with or without endovenous stenting is required emergently in those with airway compromise or symptoms secondary to cerebral edema. Definitive treatment in those with malignancy is multidisciplinary; this requires radiotherapy, chemotherapy, SVC stenting, oncologic surgery and SVC bypass or reconstruction. Endovascular treatment is the primary modality for palliation in malignancy and in those with benign etiology. Surgery is reserved for those who have failed or are unsuitable for endovascular treatment. In patients with benign disease endovenous stenting and open surgery provide excellent symptom relief and are safe and effective.

The Effectiveness of PAlliative Split COurse RAdiotherapy (PASCORA) Regimen in Non-Metastatic Head and Neck Cancer Patients Who are Treated with Palliative Intent – A Retrospective Single Center Study

<h3>Purpose/Objective(s)</h3> We at our center practice a PAlliative Split COurse RAdiotherapy (PASCORA) of 22.5Gy in 5 fractions followed by a gap of 4 weeks and then again repeat 22.5Gy in 5 fractions for Locally advanced squamous cell carcinoma patients treated with a palliative intent. Our Primary aim is to determine the symptomatic relief at 3 months after completion of PASCORA regimen. Our secondary objective is to evaluate the Overall Survival (OS) in our patients <h3>Materials/Methods</h3> 49 Patients with histologically proven LAHNSCC between January 2014 to January 2021, planned for PASCORA regimen were evaluated. Retrospectively patient, tumor and treatment characteristics were retrieved. Symptomatic relief was assessed on an objective scale. OS was determined using Kaplan Meir survival curves <h3>Results</h3> Median age was 61 years, Multiple comorbidities (37%) were the most commonly documented reason for these patients being treated with a palliative intent. 25% of our patients had an excellent symptomatic relief, 26% of our patients had a good symptomatic relief and 31% had a partial relief. Median OS was 38 months in patients who had an excellent symptomatic relief and 3-8 months in patients with no or partial symptomatic relief (p value=0.000) 6% of our patients had Grade 3 /4 RTOG toxicity <h3>Conclusion</h3> PASCORA regimen offers a good symptomatic relief with good local control rates and acceptable level of toxicity and comparable OS. However, a larger prospective study with a greater number of patients and a longer follow up would be required to confirm the same

Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias

Introduction: Although laparoscopic Nissen fundoplication is the most common procedure for the repair for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation but greater morbidity. Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH. This study reviews the results of this technique. Methods: A retrospective review was performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick Scale. Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram or endoscopy. The preoperative data was compared to the results at 2 years. Results: 396 patients underwent RAPR. The Median GERD-HRQL score was 42 (range 38 - 45) preoperatively and 6 (range 0 - 14) at two years (p Conclusion: RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding on what operation to perform in patients with large paraesophageal hiatal hernias.

Symptomatic fibroepithelial polyp of the nipple in a pediatric patient

Skin tags are benign growths typically found on intertriginous areas of the body. The most common type of skin tag is the acrochordon, skin-colored papules with short, broad stalks. A rarer type of skin tag is the fibroepithelial polyp (FEP), which tend to be larger, with long, narrow stalks. We evaluated a pediatric patient with a nipple lesion that was intermittently painful and discolored. Simple excision and primary closure was performed with excellent results and relief of symptoms. Pathology revealed benign FEP with a few benign lactiferous ducts at the base of the specimen. While the differential for benign nipple lesions is long, with only 8 documented cases of FEP of the breast and none documented in the pediatric population, this poses a diagnostic challenge. Literature shows that FEPs can grow to a large size over time and become increasingly symptomatic. The benefits of simple excision and primary closure of FEP of the nipple include improved cosmesis, improvement in symptoms, and reassurance for patient and family with benign pathology. Given the rarity of this lesion in both location and patient population, it is important for clinicians to differentiate FEP of the nipple from other benign and malignant growths.

Robotic Transthoracic First Rib Resection for Neurogenic Thoracic Outlet Syndrome

Purpose: Neurogenic Thoracic Outlet Syndrome accounts for over 95% of patients with TOS. We report a single institution experience with robotic first rib resection in patients with Neurogenic TOS. Methods: The diagnosis of NTOS was made in patients in whom all specific localizing and diagnostic orthopedic and neurologic conditions were ruled out. Preoperative diagnostic tests included a comprehensive history and physical exam, Chest X-ray, Chest CT, MRI if the cervical spine, Nerve conduction studies, and Magnetic Resonance angiography of the Thoracic outlet with arm maneuvers (MRA). Patients with NTOS who underwent robotic first rib resection with disarticulation of the costosternal joint and scalenectomy. Results: There were 137 patients (47 men and 90 women). Mean age was 34 ± 9.5 years. Operative time was 93 minutes ± 10.3 minutes. There were no intraoperative complications. There was no injury to the subclavian vessels during the dissection. There were no neurovascular complications. There was no 30 or 90 day mortality. Quick DASH Scores (Mean ± SEM) decreased from 60.3+/2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period, and 3.5+/1.1 at 6 months. (P Conclusions: Robotic resection of the medial aspect of the first rib with disarticulation of the costo-sternal joint is associated with excellent relief of neurologic symptoms in patients with Neurogenic Thoracic Outlet Syndrome.

Management of ureteropelvic junction obstruction in an era of minimally invasive surgery

IntroductionIn an era of minimally invasive surgery, laparoscopic pyeloplasty has emerged as an alternative to conventional open pyeloplasty. Although the open method boasts a success rate of over 90%, laparoscopic pyeloplasty far exceeds patient satisfaction due to its low perioperative morbidity. The aim of this study was to evaluate the outcome of patients who underwent laparoscopic pyeloplasty due to congenital ureteropelvic junction obstruction (UPJO). Material and Methods A retrospective observational study was conducted at Sri Jayawardenapura general hospital from March 2014 to December 2020. All patients were subjected to CT urogram and diuretic renogram (DTPA) scan. Clinical, imaging and biochemical findings were recorded. Patients included were those who underwent laparoscopic pyeloplasty based solely on the clinical severity of the disease, those who underwent lap-nephrectomy or open surgery was excluded. Follow up was based on clinical and DTPA scan findings. Improvement in symptomatology, split renal function(SRF) by 5% and/or diuretic curve pattern were considered successful outcomes. Results A total of 40 patients who underwent LP were evaluated with a mean age of 32 years and slight male preponderance. The majority (82.5%) were symptomatic with pain and/or infection. All were diagnosed with hydronephrosis with impaired DTPA. An SRF &lt; 40% in the affected kidney was observed in 22(55%) of patients. Concomitant pyelolithotomy was performed in 7(17.5%) patients. Mean hospital stay was 3.5 days. At mean follow up of 22-months, improvement in symptoms were noted in 35(87.5%) patients and SRF improvement (&gt;5%) were noted in 11(27.5%); the function remained stable in 27(67.5%) and deteriorated in 2(5%) of patients. Discussion Although LP is technically demanding, it offers excellent symptomatic relief and renal preservation. It offers less morbidity, better aesthetic and post-operative convalescence: a promising viable option replacing open surgery.

Unilateral Isolated Inferior Rectus Palsy: A Rare Presentation of Ocular Myasthenia Gravis

Ocular Myasthenia Gravis with unilateral isolated Inferior Rectus palsy and no ptosis is rarely encountered. We present a case of 25-year-old male with sudden onset binocular diplopia and no features of ptosis. Deviations in primary gaze were 3-8 Prism Dioptre (PD) with left hypertropia. Right and left head tilt deviations were 5PD and 3PD left hypertropia respectively with increase in hypertropia in left gazes. Acetylcholine receptor binding antibodies were found to be raised. Repetitive Nerve Stimulation showed decreased amplitude. Patient was managed with Oral Pyridostigmine with excellent symptomatic relief and drug tolerance. No features of Myasthenia Gravis (Systemic or Ocular) were noted on follow-up.

Management of de Quervain Tenosynovitis: A Critical Analysis Review.

Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments. For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby. When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision. For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury. Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.

Elective Resection of Symptomatic Arteriovenous Fistulae and Grafts in Patients with Functioning Renal Allografts at A High Volume Transplant Hospital

Patients with functioning renal allografts may need ligation of pre-existing hemodialysis conduits. Chronic immunosuppression for renal allografts may adversely affect wound healing and perioperative complications following these procedures. We sought to analyze outcomes following elective ligation and resection of symptomatic arteriovenous (AV) access in immunosuppressed patients with renal allografts no longer requiring dialysis at a high-volume renal transplant hospital. We retrospectively reviewed procedure codes for hemodialysis access resection and revision from 2014-2020 at a single academic tertiary care hospital. Patients who underwent complete or subtotal dialysis access resection with a functioning renal allograft were included for analysis of preoperative, operative, and postoperative outcomes. We performed descriptive statistics, and student's t-test using Microsoft Excel. Thirty-four patients met inclusion criteria. The majority were male, 56%, and the most common causes of renal failure were hypertension and diabetes, respectively. Ligation and resection of proximal upper extremity access was performed in 68%. The mean operative time was 126 minutes with pain being the most common indication for intervention. Four patients required arterial reconstruction. Mean postoperative follow-up was 13 months. Arm pain and swelling resolved in 100% and 88% of patients following AV access resection, respectively. No impairment in mean postoperative glomerular filtration rates were noted. One patient required hemodialysis and died three months after fistula resection following complications from treatment of a newly diagnosed neuroendocrine tumor and subsequent fungemia, CONCLUSION: Elective operative resection of symptomatic AV access may be performed safely in immunosuppressed patients with functioning renal transplants. The risk of allograft impairment and/or failure as a result of AV access resection in our series was low. Elective ligation and resection can be achieved with low mortality, excellent symptomatic relief, and few wound complications despite chronic immunosuppression.

A Novel Technique for the Management of AtlantoAxial OsteoArthritis (AAOA)

Purpose: This study presents a conservative approach and a novel technique for managing Atlantoaxial Osteoarthritis (AAOA). The subaxial cervical joints have a five joint complex, while C1-C2 joint is a three joint structure which makes it undergo biomechnaically increased stress. Atlantoaxial Osteoarthritis (AAOA) is more commonly associated with the elderly age group, especially women. Most of these patients improve with conservative treatment, while few require surgical fixation. Materials and Methods: Three hundred thirty-eight patients were analysed from the database (2009 to 2018) with a minimum follow up of 18 months. All patients presented with unilateral sub-occipital neuralgia, unilateral restricted movement, C2 radiculopathy and no myelopathy. Diagnosis of AAOA with an open mouth AP radiograph is confirmatory. Dynamic radiographs were used to diagnose instability. CT Scan was done for pre-operative evaluation, and MRI was done to rule out sinister pathologies. Results: The average age of the patients was 65.2 years (41-84 years). The majority of the patients (177) were females working as housewives. Our study didn’t have any correlation with the lifting of heavy objects on the head. The majority of the patients were treated conservatively with a soft cervical collar, and they were asked to wear it throughout the day and night, every day for two months. Patients with no symptomatic relief after conservative treatment with collar were given an intra-articular injection or greater occipital nerve block (BR Dave’s Technique). Patients not responding to conservative management with persistent instability were treated with Surgical Fixation (Trans-articular/Harms-Goel). Conclusion: The primary management is with a cervical collar; Greater Occipital Nerve Block (BR Dave’s technique) or Intra-articular block provides excellent symptomatic relief. Keywords: Arthritis, Atlantoaxial, Nerve block, C1C2 instability, C1C2 fusion

Late Health Status of Patients Undergoing Myectomy for Obstructive Hypertrophic Cardiomyopathy

Surgical myectomy eliminates symptoms in most patients with obstructive hypertrophic cardiomyopathy, but dyspnea and/or angina can recur in some. This study investigated clinical features associated with a lack of clinical improvement postoperatively. Between March 2007 and December 2012, 963 patients underwent transaortic septal myectomy at our clinic. Six hundred one patients received standardized follow-up questionnaires, which were answered by 409 (68.1%). We compared clinical characteristics of patients with and without improvement and identified predictors of worsening health using a multivariable proportional odds ordinal logistic model. Of 409 patients, 329 (80.4%) indicated better health status at follow-up and 80 (19.6%) responded that their health had stayed the same or worsened. The median age of patients with perceived better health was 56.8 years (interquartile range, 47.4, 65.7) and those without improvement was 63.0 years (interquartile range, 50.0, 70.2). New York Heart Association class III/IV dyspnea was present in 90.3% of patients who reported improvement and in 79.7% who did not. In multivariable analysis the presence of coronary artery disease (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.17-6.50; P= .020), lower preoperative left ventricular ejection fraction (per interquartile range increase: OR, 0.76; 95% CI, 0.57-0.99; P= .047), and worse preoperative health status (eg, poor or fair: OR, 1.63; 95% CI, 1.05-2.54; P= 0.004) were associated with worse health status at follow-up. Septal myectomy leads to excellent symptomatic relief in most patients, and more than 80% report subjective improvement in health status. Important predictors of worsening health included coronary artery disease and poor preoperative health status.

Management of Recurrent Symptomatic Macromastia: A Single Surgeon’s Experience

Abstract Background Breast reduction for symptomatic macromastia can have excellent long-term results and relief of symptoms. However, patients may require a re-reduction for recurrent symptoms. Previous reports of re-reduction after a primary inferior pedicle reduction have called into question the safety of blood supply to the nipple-areola complex with re-reduction. Objectives To examine a single surgeon’s experience and management of recurrent symptomatic macromastia after inferior pedicle breast reduction. Methods A retrospective review was performed of a single surgeon’s breast reduction experience using billing data to identify cases of breast re-reduction from January 2003 and January 2018. Breast re-reduction was performed either with a Wise pattern, inferior pedicle or with a smile reduction with an inferior pedicle. Liposuction was used in re-reductions only. Results In 15 years, 3530 breast reductions were performed in 1758 patients. In 7 patients, 14 total re-reductions were performed, including 13 secondary breast re-reductions (12 bilateral, 1 unilateral) and 1 tertiary, unilateral breast re-reduction. Seven Wise pattern, inferior pedicle and 7 smile reductions with inferior pedicle procedures were done at the breast level. This translates to a re-reduction incidence of 1 in 250 or 0.4% rate of re-reduction at the patient level in our practice. The minor complication rate was 14% (1 seroma), and the major complication rate was 0%. There were no instances of partial or complete nipple areola necrosis. Conclusions Recurrent symptomatic macromastia can be managed with re-reduction with re-creation of the inferior pedicle or a smile breast reduction as we describe without increased risk to nipple-areolar complex viability. Level of Evidence: 4

Tumoral calcinosis of the lumbar and cervical spine

BackgroundTumoral calcinosis has been defined as a pathological condition which presents as calcified masses around juxta-articular structures. The etiology of this pathology is still not well understood but degenerative spine diseases seem to play a role. The diagnosis of tumoral calcinosis preoperatively can prevent intraoperative confusion from unexpected findings, especially in cases where removal of the calcified mass is essential to treating the patient’s symptoms, i.e. nerve compression causing radiculopathy. Case descriptionWe present two cases of patients who presented with spinal radiculopathy and mechanical pain. Both patients were found to have a calcified facet joint mass and underwent surgical resection of the mass combined with spinal fusion resulting in excellent symptom relief post-surgery. ConclusionFor accurate diagnosis and management of tumoral calcinosis, a high index of suspicion together with neuro imaging remains a good place to start. Intra-operative visualization of the pathology as well as permanent pathology reports is a good adjunct to confirming the diagnosis.

Hybrid Operating Room Settings for Treatment of Complex Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (dAVFs) are abnormal direct shunts between the occipital or meningeal artery and a meningeal vein or dural venous sinus. Treatment strategies include endovascular, microsurgical, stereotactic radiosurgical, or combined interventions. With few previous reports focused on dAVF treatment in a hybrid operating room (hOR), the authors reviewed their 6-year experience in this unique setting for these complex fistulas. Patients with complex cerebral dAVFs underwent endovascular and microsurgical treatment in the hOR. In this retrospective review, 8 consecutive patients with cerebral dAVFs (Borden type 2 or higher) underwent endovascular and microsurgical treatment. Demographic characteristics, symptoms related to the dAVF, preoperative angiographic features, preinterventional therapies, intraoperative digital subtraction angiography (iDSA), and postoperative clinical and radiologic findings were reviewed. Of these 8 patients, 5 patients underwent multiple embolizations (up to 3) and hybrid procedures, with no procedure-related complications. After microsurgical resection, iDSA revealed remnants of the fistula, which was then immediately re-resected, in 2 patients. At closing of the hybrid procedure, iDSA revealed no fistula remnants in 7 patients (88%). At mean follow-up examination (58 months), 5 patients (62%) had cure of the dAVF, confirmed by noninvasive angiography. Two patients (25%) experienced a recurrence of the dAVF within 5 months. Our hybrid techniques achieved high rates of dAVF obliteration, with all 8 patients achieving good or excellent outcomes and symptom relief. Angiographic follow-up within 6 months after the hybrid procedure is recommended for all patients even when intraoperative findings do not show remnants.