Final Surgical Outcome Research Articles

Expert Consensus for the Treatment Algorithm for Navigationassisted Reconstruction of Maxillofacial Deformities.

Deformities of the maxillofacial region following trauma and ablative surgery are devastating and not uncommon. Reconstruction of such defects is a surgically challenging procedure. Conventionally, reconstruction of dental arch defects lacks preoperative customised planning and relies heavily on the surgeon experience to ensure optimum surgical outcomes. The restoration of the dental arch shape and function has taken precedence after an extensive tumour resection surgery, especially in the current age of technological advancement. Thus, personalised and accurate reconstruction of dental arch defects has become a new goal. Computer-assisted surgery, especially navigation-assisted surgery, has gained popularity of late, in reconstructing deformities and restoring facial symmetry, appearance and function in the maxillofacial region. This technology provides a clearer three-dimensional visualisation of the area of interest and its relationship with the adjacent vital structures. Together with preoperative virtual surgical planning, it allows more specific and accurate osteotomies, thus reducing the ischemia and total operating times substantially. The risk of complications is also minimised whilst improving the final surgical outcomes. The use of the intraoperative navigation system and other computer-assisted surgical techniques during surgery can significantly improve the precision of the reconstruction of dental arch deformities, and achieve personalised and functional reconstructive goals while enhancing the quality of life of patients postoperatively. The Society of Oral and Maxillofacial Surgery, Chinese Stomatological Association provides the present professional perspective and treatment protocol for navigation-guided reconstruction of dental arch defects, to allow standardisation of the technique while promoting its application among oral and maxillofacial surgeons.

Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty after Gender-Affirming Genital Surgery.

Penile inversion vaginoplasty is the most common gender-affirming procedure for transfeminine patients. Patients undergoing this procedure may require revision labiaplasty and clitoroplasty. This study describes complications and outcomes from the largest reported cohort in the United States to undergo penile inversion vaginoplasty with subsequent revision labiaplasty and/or clitoroplasty. A retrospective chart review was performed of a single surgeon's experience with penile inversion vaginoplasty with or without revision labiaplasty and/or clitoroplasty between July of 2014 and June of 2016 in a cohort of gender-diverse patients assigned male at birth. Patient demographic data, complications, and quality of life data were collected. Univariate and multivariate comparisons were completed. A total of 117 patients underwent penile inversion vaginoplasty. Of these, 28 patients (23.9 percent) underwent revision labiaplasty and/or clitoroplasty, with nine patients (7.7 percent) undergoing both procedures. Patients who underwent penile inversion vaginoplasty necessitating revision were significantly more likely to have granulation tissue (p = 0.006), intravaginal scarring (p < 0.001), and complete vaginal stenosis (p = 0.008). The majority of patients who underwent revision labiaplasty and/or clitoroplasty reported satisfaction with their final surgical outcome (82.4 percent) and resolution of their genital-related dysphoria (76.5 percent). Patients who developed minor postoperative complications following penile inversion vaginoplasty were more likely to require revision surgery to address functional and aesthetic concerns. Patients responded with high levels of satisfaction following revision procedures, with the majority of patients reporting resolution of genital-related dysphoria. Transfeminine patients who undergo penile inversion vaginoplasty should be counseled on the possibility of revisions during their postoperative course. Therapeutic, III.

Primary Probing with and without Monoka Silastic Stent Intubation for Epiphora in Older Children and Adults

ABSTRACT Purpose To report the results of primary probing with and without monocanalicular silastic stent intubation for the relief of chronic epiphora in older children and adults and to assess its effectivity on final surgical outcome. Materials and methods An uncontrolled surgical trial was designed. A total of 124 eyes of 102 patients (90 female, 12 male; 80 unilateral, 22 bilateral) with uncomplicated nasolacrimal ductus obstruction had primary probing with and without monocanalicular silastic stent intubation by a Ritleng probe. Symptomatic relief of epiphora and positive dye test were established as success. The time of the operation was measured, the success rate was assessed, the advantages and disadvantages were evaluated and the surgical outcome was compared with our previous papers. Results The mean age of the patients was 37.2 years (range, 6–59) with a mean follow-up period of 14.7 months (range, 6–24). The symptoms were present for a mean of 2.5 years (range, 6 months–5 years). Of 124 eyes, 21 cases underwent only primary probing whereas the remaining 103 had primary probing with monocanalicular silastic stent intubation. The operative time was 4.3 min (range, 3–12). The silastic stents were removed between third to six months. The overall success rates at the first visit (2 weeks after stent removal) and the last visit were 58.5% and 45.2% (56 cases), respectively. None of the cases demonstrated any per- or postoperative complications. All 68 failure eyes underwent uneventful external dacryocystorhinostomy, 65 (95.5%) of which were successful with the relief of previous symptoms at final visit. Conclusions Primary probing with or without monocanalicular silastic stent intubation may be tried initially in older children and adults with complete nasolacrimal duct obstructions, as this intervention does not prevent further possible conventional dacryocystorhinostomy in case of failure, speeds up the procedure, and avoids the disadvantages of invasive approaches.

Total Knee Arthroplasty: The Efficacy of Calcium Sulfate Beads in One-Stage Aseptic Revision

Background: The risk of periprosthetic joint infection following revision total knee arthroplasty is high, as is the cost of care. Decreasing periprosthetic joint infection risk may include utilization of calcium sulfate beads. Calcium sulfate beads have been gaining momentum in treating infected joints because of their potential advantages, including antibiotic elution and dissolvability. However, literature documenting their utilization in aseptic revision is sparse. This study compares: 1) infection rates; 2) length of stay; 3) subsequent infection procedures; and 4) final surgical outcome between one-stage aseptic revision total knee arthroplasty patients who received calcium sulfate beads and those who did not. Methods: We performed a retrospective chart review to identify patients who underwent aseptic one-stage revision total knee arthroplasty between January 2013 and December 2017. Outcomes collected included postoperative infection rate, length of stay, subsequent irrigation and debridement, and final surgical outcome, classified as a successful total knee arthroplasty reimplantation, a retained antibiotic spacer, or an above knee amputation. Chi-square analysis was used to analyze all categorical variables, while Student’s t-testing was used for continuous variables. A p-value of 0.5 was set as the threshold for statistical significance. Results: Calcium sulfate bead patients did not differ from non-calcium sulfate bead patients with regard to the number of postoperative infections (p=0.103), lengths of stay (p=0.210), irrigation and debridement procedures (p=0.063) and surgical outcome (p=0.085). Conclusion: Patients who received calcium sulfate beads had analogous surgical outcomes and infection rates to non-calcium sulfate bead patients. The use of calcium sulfate beads in aseptic one-stage revision total knee arthroplasty may not be beneficial in preventing infection and reducing costs.

Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes

Rapid increase in number of male-to-female vaginoplasties emphasizes the need for preoperative measures to optimize final surgical and patient-reported outcomes. Hormonal therapy and socioeconomic factors may contribute to a higher incidence of pelvic floor dysfunction in patients undergoing male-to-female vaginoplasty. The purpose of this study was to evaluate the incidence of pelvic floor dysfunction in this population and the role of physical therapy in its treatment. From July 2016 to July 2018, patients scheduled to undergo male-to-female vaginoplasty were evaluated by a physical therapist for pelvic floor dysfunction. Patient charts were reviewed for demographics, comorbidities, and length of hormonal therapy. Those with and without symptoms were compared. Symptomatic patients underwent therapy. Assessment of symptom severity and its impact on daily living were completed at 2- to 3-month intervals with physical therapy using the 6-item Urinary Distress Index 6 and 8-item Colorectal Anal Distress Index components of the 20-item Pelvic Floor Distress Inventory (PFDI-20) before and after surgery. A third component of the PFDI-20, the 6-item Pelvic Organ Prolapse Distress Inventory, was also included in the postoperative assessment. Over a 24-month period, a total of 40 patients with a mean age of 40.7 (19-72) years and body mass index of 27.1 kg/m (22-39 kg/m) were enrolled. Comorbidities included 4 patients (10%) with diabetes and 6 patients (15%) with hypertension. Patients with symptoms had a significantly higher mean age (P < 0.01). Only 1 patient (2.5%) had new-onset pelvic floor dysfunction after surgery, and there was no significant increase in severity of symptoms in those with a previous pelvic floor dysfunction postoperatively. Physical therapy significantly (P < 0.01) reduced severity of symptoms and its impact on daily living as assessed by the Urinary Distress Index and Colorectal Anal Distress Index before and after surgery and by the PFDI-20 and 7-item Pelvic Floor Dysfunction Index postoperatively. A high incidence of pelvic floor dysfunction may exist in patients undergoing male-to-female vaginoplasty preoperatively. Screening at this early stage with both preoperative and postoperative therapy can significantly reduce pelvic floor dysfunction and improve symptoms and quality of life for this population.

Expert consensus on techniques of navigation-guided reconstruction of jaw defect

Deformities of the maxillofacial region following trauma and ablative surgery are devastating and not uncommon. Reconstruction of such defects is a surgically challenging procedure. Conventionally, reconstruction of the jaw defects lacks pre-operative customized planning and relies heavily on surgeons' experiences to ensure optimum surgical outcomes. The restoration of jaw shape and function has taken precedence after an extensive tumor resection surgery, especially in the current age of technological advancement. Thus, personalized and accurate reconstruction of jaw defects has become a new goal. Computer-assisted surgery especially navigation-assisted surgery has gained popularity of late, in reconstructing deformities and restoring facial symmetry, appearance and function in the maxillofacial region. This technology provides a clearer three-dimensional visualization of the area of interest and its relationship with the adjacent vital structures. With pre-operative virtual surgical planning, it allows more specific and accurate osteotomies, thus reducing the ischemia and total operating times substantially. The risk of complications is also minimized whilst improving the final surgical outcomes. The use of intra-operative navigation system and other computer-assisted surgical techniques in the surgery can significantly improve the precision of the reconstruction of jaw deformities and achieve personalized and functional reconstructive goals while enhancing the patients' quality of life post-operatively. The Society of Oral and Maxillofacial Surgery, Chinese Stomatological Association provides this professional perspective and present treatment protocol for navigation-guided reconstruction of jaw defect to allow standardization of the techniques while promoting its application among the oral and maxillofacial surgeons.

Conventional Dacryocystorhinostomy Versus Pawar’s Implant Dacryocystorhinostomy- A Prospective Study

Purpose: To compare conventional dacryocystorhinostomy (DCR) with Pawar’s intracystic implant dacryocystorhinostomy in terms of surgical technique, complications and success rate for primary acquired nasolacrimal duct obstruction (NLDO).&#x0D; Materials and Methods: This is a prospective comparative, nonrandomized, clinical study. It is carried out on 50 cases of primary acquired NLDO. The 50 cases were divide into two groups; Group A consisting of 30 cases that underwent Pawar’s intracystic implant DCR whereas Group B consisting of 20 cases those operated by conventional DCR technique.&#x0D; Data regarding demographic profile of patients, mode of presentation, diagnosis, intraoperative variables such as surgical duration, intra- and post-operative complications, hospital stay and causes of failure and final surgical outcome, were analyzed. Clinical success was defined as patent lacrimal system on irrigation (objective) and absence of symptoms (subjective).&#x0D; Results: Out of 50 cases 40 (80%) were female and 10 cases (20%) were males. In this study, 39 (78%) cases had chronic dacryocystitis, followed by pyocele/mucocele 5 (10%), chronic dacryocystitis with lacrimal fistula 3 (6%), and previous failed DCR surgery 3 (6%).&#x0D; Hemorrhage from nasal mucosa was observed in 9 cases (45%) during conventional DCR surgery and one case (3.33%) in implant DCR. Hemorrhage from angular vein occurred in 1 case (5%) during conventional DCR. Nasal mucosa was disrupted/damage in 8 cases (40%) during conventional DCR. The average operating time in convention DCR is 110.50 minutes while for Pwar’s implant DCR is 27.33 minutes. The commonest post-operative complication of Pawar’s intracystic implant DCR was obstruction of passage found in 4 cases (13.33%). Hypertrophic scar was the most common postoperative complication in 8 cases (40%) in conventional DCR. Success rate of implant DCR at 2 months follow up was 83.33% and at the end of 3 months after management of failed cases of implant DCR was 96.66%. Success rate of conventional DCR at 2 months follow up was 80% and at the end of 3 months after management of failed cases of conventional DCR was 85%.&#x0D; Conclusion: The success rate of Pawar’s intracystic implant DCR is comparable with conventional DCR with additional advantages such as easy, quick, minimal intra- and post operative complication and possibility of conventional DCR in future in failed Pawar’s implant DCR.

The role of drug-induced sleep endoscopy: predicting and guiding upper airway surgery for adult OSA patients.

Obstructive sleep apnea (OSA) is a common sleep disorder that can be corrected with upper airway surgery. Prior to surgery, drug-induced sleep endoscopy (DISE) is routinely used to evaluate obstruction sites and severity. Evidence suggests that the findings of DISE may relate to the final surgical outcome. Therefore, we evaluated the ability of drug-induced sleep endoscopy to predict the final effect of upper airway surgery and potentially to guide surgical treatment decision-making. A retrospective analysis was conducted on 85 adult patients with OSA (50 men with mean apnea-hypopnea index [AHI] 30 ± 15events/h) who underwent DISE followed by tonsillectomy, uvulopalatopharyngoplasty (UPPP), or a combination of the two. Surgery outcome was evaluated at follow-up by polysomnography. Success response to surgery was defined as a postoperative value of the AHI< 20events/h and more than 50% postoperative reduction of AHI. Of the 85 patients evaluated, 48 (53%) were responders. DISE revealed significant differences between the two groups. Specifically, complete circumferential collapse at the velum and complete anterior-posterior collapse at the tongue base occurred at higher frequencies in nonresponders. In contrast, the presence of grade 3-4 tonsillar hypertrophy and anterior-posterior mild/partial collapse at the velum were positively associated with responders. Our results suggest that DISE may help predict the final outcome of tonsillectomy, UPPP, or a combination of the two in adult patients with OSA. The use of DISE shows potential to guide treatment decisions for individual patients with OSA.

Umbilical Hernia with Evisceration. Two Cases and a Review of the Literature

BackgroundEvisceration of umbilical hernias is an uncommon occurrence whereby the hernial contents break through the skin overlying the sac and skin. Irrespective of cause, sudden evisceration of an umbilical hernia is associated with deterioration and a poor outcome. Case ReportsOur first case was a 42-year-old woman who presented with sudden outpouring of fluid from the umbilicus with omental evisceration. Further evaluation revealed hepatic decompensation caused by hepatitis C infection belonging to Child-Turcotte-Pugh class C. After stabilizing her hemodynamically, she underwent a partial omentectomy with primary repair of umbilical defect. The patient's postoperative course was challenging. She died of septicemia and acute renal failure after 5 days. Our second case was a 40-year-old man who suffered from alcohol-induced cirrhosis, presenting with omental evisceration, belonging to Child-Turcotte-Pugh class C. We performed a primary repair of the hernial defect with peritoneovenous shunting for his intractable ascites. Upper gastrointestinal endoscopy revealed grade I esophageal varices. The patient succumbed to acute variceal hemorrhage with acute renal failure 18 days later. Why Should An Emergency Physician Be Aware of This?In an emergent setting with multiple factors influencing final surgical outcome, it is imperative that management be tailored for each patient. Those with severe encephalopathy or cardiovascular instability must be stabilized before surgical intervention. Central venous and blood pressures need to be closely monitored during resuscitation, as fervent fluid administration may predispose to variceal hemorrhage. It may be prudent to follow the principle of hypotensive resuscitation as in acute trauma cases.

Efficacy external fixator in the management of infected nonunion fractures

Management of infected nonunion of fractures is a difficult task for orthopedic surgeons in a manner to create bony stability, in recovery of soft tissue and fracture union. Several surgical treatment modalities have been available like bone grafting, antibiotic treatment, ilizarov methods and free soft tissue transfer. This study was conducted to assess the role of monolateral external fixators in infected nonunion of fractures. A total 40 infected nonunion cases were recruited based on AO classification. Patients with wounds of minimum 3 months were considered as non- draining cases. Blood investigations, microbiological investigation and radiological investigation were done. Special attention was focused on limb length measurements, range of motion of the joints, neuromuscular status and distal vascularity. The final surgical outcome was assessed asper ASAMI’S criteria with grade system. Among the cases, 65% nonunion fractures were observed in femur, 22.5% in tibia and 12.5% in humerus. Superficial pin tract infections was noticed in 48% cases and are responded to oral antibiotics. The final surgical outcome indicates that 90% cases had grade-I & II (excellent and good) recovery from infected nonunion fractures in bony and functional recovery. The monolateral external fixation system is effective and convenient method for the treatment of infected nonunion of long bones and is most reliable to rectify the limb length discrepancies.

Comparison of the Outcome of Diathermy Versus Scalpel Skin Incision in Surgical Cases

The objective of this study was to compare the outcome of cutting diathermy incisions versus surgical scalpel incisions in three different sites of elective surgery. This study was a prospective observational study conducted at a tertiary care teaching hospital in Pune, India, over a period of 2 years from June 2014 to June 2016 including a 1-year follow-up period. Inclusion criteria were patients of both sexes who were admitted for elective surgeries of the thyroid, breast, and abdomen. Data including demographic details, infection rate, and cosmetic appearance were recorded in both groups to compare the final surgical outcome. A total of 135 patients were finally analyzed in the study. A total of 68 patients (group A) underwent operation via diathermy skin incision and 67 patients (group B) underwent operation via scalpel skin incision. In diathermy (group A), a total 18% (n = 12) patients developed complications and in scalpel (group B), a total 21% (n = 14) patients developed complications (chi-square = 2.386, p value = 0.801). In diathermy (group A), 56 cases (82%) had excellent scar, 12 cases (17%) had fair scar, and 1 case (1.5%) had poor scar. In scalpel group (group B), 53 cases (79%) had excellent scar, 12 cases (18%) had fair scar, and 2 cases (3%) developed poor scar (f = 2.56, p = 0.112). No significant difference was noted in wound healing and the rate of wound complication in skin incision made by cutting diathermy as compared to the conventional scalpel skin incision in our present study. We also conclude that there is no difference in cosmetic outcome in both groups after 1 year of follow-up.

Reflector-guided breast tumor localization versus wire localization for lumpectomies: A comparison of surgical outcomes

PurposeTo compare surgical outcomes of SAVI SCOUT reflector localization (SSL) versus wire localization (WL) for breast tumors. MethodsRetrospective review of 42 SSL cases and 42 WL cases. WL patients were consecutively matched for clinical-pathologic features. Final surgical outcome measures were tumor specimen volume, margin status, and re-excision rates. ResultsNo significant differences were present in median specimen volumes (SSL-15.2cm3 vs. WL-16.3cm3), positive margin rate (SSL-9.5% vs. WL-7.1%), close margin rate (SSL-7.1% vs. WL-11.9%) or re-excision rate (SSL-7.1% vs. WL-9.5%). ConclusionSSL is an acceptable alternative to WL with no significant differences in surgical outcomes.

Next-Generation Sequencing Identifies Gene Mutations That Are Predictive of Malignancy in Residual Needle Rinses Collected From Fine-Needle Aspirations of Thyroid Nodules.

- Thyroid nodules have a prevalence of approximately 70% in adults. Fine-needle aspiration (FNA) is a minimally invasive, cost-effective, standard method to collect tissue from thyroid nodules for cytologic examination. However, approximately 15% of thyroid FNA specimens cannot be unambiguously diagnosed as benign or malignant. - To investigate whether clinically actionable data can be obtained using next-generation sequencing of residual needle rinse material. - A total of 24 residual needle rinse specimens with malignant (n = 6), indeterminate (n = 9), or benign (n = 9) thyroid FNA diagnoses were analyzed in our clinical molecular diagnostics laboratory using next-generation sequencing assays designed to detect gene mutations and translocations that commonly occur in thyroid cancer. Results were correlated with surgical diagnoses and clinical outcomes. - Interpretable data were generated from 23 of 24 residual needle rinse specimens. Consistent with its well-known role in thyroid malignancy, BRAF V600E mutations were detected in 4 malignant cases. An NRAS mutation was detected in 1 benign case. No mutations were detected from specimens with indeterminate diagnoses. - Our data demonstrate that residual thyroid FNA needle rinses are an adequate source of material for molecular diagnostic testing. Importantly, detection of a mutation implicated in thyroid malignancy was predictive of the final surgical diagnosis and clinical outcome. Our strategy to triage thyroid nodules with indeterminate cytology with molecular testing eliminates the need to perform additional FNA passes into dedicated media or to schedule additional invasive procedures. Further investigation with a larger sample size to confirm the clinical utility of our proposed strategy is underway.

Identification of Focal Epileptogenic Networks in Generalized Epilepsy Using Brain Functional Connectivity Analysis of Bilateral Intracranial EEG Signals.

Simultaneous bilateral onset and bi-synchrony epileptiform discharges in electroencephalogram (EEG) remain hallmarks for generalized seizures. However, the possibility of an epileptogenic focus triggering rapidly generalized epileptiform discharges has been documented in several studies. Previously, a new multi-stage surgical procedure using bilateral intracranial EEG (iEEG) prior to and post complete corpus callosotomy (CC) was developed to uncover seizure focus in non-lateralizing focal epilepsy. Five patients with drug-resistant generalized epilepsy who underwent this procedure were included in the study. Their bilateral iEEG findings prior to complete CC showed generalized epileptiform discharges with no clear lateralization. Nonetheless, the bilateral ictal iEEG findings post complete CC indicated lateralized or localized seizure onset. This study hypothesized that brain functional connectivity analysis, applied to the pre CC bilateral iEEG recordings, could help identify focal epileptogenic networks in generalized epilepsy. The results indicated that despite diffuse epileptiform discharges, focal features can still be observed in apparent generalized seizures through brain connectivity analysis. The seizure onset localization/lateralization from connectivity analysis demonstrated a good agreement with the bilateral iEEG findings post complete CC and final surgical outcomes. Our study supports the role of focal epileptic networks in generalized seizures.

DIATHERMY INCISIONS V/S SURGICAL SCALPEL INCISIONS

Objectives: The objective of this study was to compare the outcome of diathermyincisions v/s surgical scalpel incisions in general surgery. Study Design: Cross sectional study.Place and Duration of Study: This study was conducted at surgical unit 7, Sindh Govt. LyariGeneral Hospital and Dow University of Health Sciences between January to December 2009.Methodology: 100 consecutive patients for elective general surgery were randomly assignedto either group A incision with cutting diathermy (n=50) or group B cold steel scalpel (n=50).Data including demographic details, hospital stay, infection rate and non-infective complicationslike swelling, bleeding, dehiscence and seroma formation were recorded in both groups tocompare the final surgical outcome compared. Results: A total of 80 patients were included inthe study, placed alternatively into two groups of 40 patients each with majority being male (n =61, 76.3%). The mean age was 22.46 years. The positive predictive value for patients of Group Awas 92.5% while for Group B was 77.5%. When diagnostic accuracy was compared on the basisof Gender for the two groups, the positive predictive value for male patients of Group A and Bwas 90.09% and 89.28% respectively, but for females the positive predictive value of Group Aand B was 100% and 50% respectively. In Diathermy (Group A) total 20% patients developedcomplications and these were seroma formation (n=4, 8%), wound dehiscence (n=3, 6%) andwound infection (n=3, 6%). In Scalpel (Group B) total 26% patients developed complications(P-value=0.370) in which seromas was noted (n=5, 10%) then wound infection (n=4, 8%), thenwound bleeding (n=3, 6%) and lastly seroma formation (n=1, 2%). Hospital stays were alsoalmost similar with mean value 8.24 days in diathermy group and 10.54 days in scalpel group.No remarkable difference in demographics, characteristics and in other variables of patientswas noted. Conclusion: We conclude that no significant difference in surgical outcome ofboth groups (cutting diathermy Vs. steel scalpel). Therefore, use of either technique to createsurgical wound merely depends upon preference of surgeon.

A new approach for sutureless 20-G vitrectomy

Aim of the work To assess the safety and the effectiveness of a new approach for sutureless 20-G pars plana vitrectomy using N -butyl-2-cyanoacrylate 'Histoacryl' glue, aiming for the conversion of the conventional 20-G vitrectomy to a sutureless technique. Design An interventional study. Patients and methods About 40 eyes of 40 patients attending the surgical retina clinics of the Research Institute of Ophthalmology were subjected to the new technique. The selection criterion included patients with diabetic and nondiabetic vitreous hemorrhage, rhegmatogenous retinal detachment (RD), recurrent RD, pseudophakic RD, giant retinal breaks, macular hole, proliferative diabetic retinopathy, complications of anterior segment surgery, posterior dislocated IOL, vitreomacular traction syndrome, macular pucker, idiopathic epiretinal membrane, and dropped nucleus. Patients were selected randomly. There was no age limitation, sex choice, or race preference. All the patients underwent a modified 20-G sutureless vitrectomy surgery. Periotomy was performed in the upper part of the eye, and the sclera was exposed, three 1/2-thickness scleral flaps were fashioned using a crescent knife for a length of 2 mm, and a 20-G self-retaining infusion cannula was introduced at the 12 O'clock position. At the end of the surgery, Histoacryl tissue glue was applied to close the scleral flaps and the conjunctiva. Different vitreal substitutes and tamponades were used according to the case. All the patients had undergone ultrasonic biomicroscopy at the sclerotomy sites 6 weeks postoperatively. Our main concern was to assess the success and the effectiveness of the procedure, wound integrity, intraoperative and postoperative complications, the efficacy of the N -butyl-2-cyanoacrylate to hold the tissues, tissue reaction related to cyanoacrylate, patients' satisfaction, and the final surgical outcome. The postoperative intraocular pressure (IOP) and the Snellen visual acuity relative to the preoperative values were recorded. Patients were evaluated postoperatively on the first day, the first week, and then weekly for 1 month and monthly for 6 months or till the time of removal of silicone oil, which was also removed by the same aforementioned technique. Results The proportion of male patients was 47.5% (19 patients) and that of female patients 52.5% (21 patients). The mean age of the male patients was 49 ΁ 12.5 years, whereas the mean age of the female patients was 44 ΁ 15.5 years. Different vitreous substitutes/tamponades were used, including air, SF6, ringer lactate, and silicon oil 5000 cSt. The mean operative time was 61.75 ΁ 13.8 min and the mean time fashioning and closing the sclerotomies and the conjunctiva was 7 ΁ 1.8 min. No sclerotomy-related intraoperative difficulties or complications were seen and none of the patients required stitching of the sclerotomies at the end of the surgery. All patients were discharged from the hospital immediately after the surgery. Ultrasonic biomicroscopy (UBM) revealed complete wound closure in 36 patients (90%), partial internal wound dehiscence in four patients (7.5%), and three patients (10%) showed microcyst formation under the conjunctiva. Postoperative hypotony was not seen in any of the patients.There was no single case of endophthalmitis or chemical uveitis. The visual acuity was improving along the follow-up period, except for one uncontrolled diabetic patient, who developed rubeosis iridis and the condition deteriorated. Most patients presented with an initial increase in the IOP followed by stabilization of the IOP thereafter. Conclusion The new approach of 20-G sutureless vitrectomy utilizing N -butyl-2-cyanoacrylate is a safe and effective technique for the surgical treatment of a variety of vitreoretinal pathologies. Conversion to this technique is very simple. A very short learning curve is required, with no need for new expensive instrumentation. It combines all the advantages of 20-G vitrectomy, adding to it the sutureless advantage of the technique.

Cranial distraction osteogenesis: a proposal of minimal consolidation period.

Cranial distraction osteogenesis (DO) has many advantages for correcting skull deformities: Thus, DO is extensively used for the treatment of skull deformities. However, diverse, unexpected complications are associated with this procedure. In this study, we present the surgical outcomes and complications of DO. Moreover, we propose a modified protocol for DO to reduce complications. This is a retrospective study on managed patients that underwent DO between March 2008 and May 2013. Their clinical courses were reviewed. Distraction protocols were individually inspected, and the final surgical outcomes, including complications, were evaluated. During the study period, a total of ten patients (seven boys and three girls) were treated at our institute. The median distraction period was 20.5days (ranging from 17 to 50days). The range of total distraction length was 19-22mm. The median consolidation period was 96days (ranging from 0 to 343days). All patients achieved the goals of distraction. At follow-up evaluations, all patients, except one, showed good surgical outcomes in both head shape and neurologic symptoms. There were six patients with wound complications during the treatment period. Among them, the distractors were removed early in three patients. Interestingly, even these three patients, without a sufficient consolidation period, showed good outcomes. Although DO has many merits for correcting skull deformities, it frequently causes severe wound complications. To reduce these complications, we propose a modified protocol with a minimal or even no consolidation period.

Therapeutic surgery without a definitive diagnosis can be an option in selected patients with suspected lung cancer.

With the recent improvements in the diagnostic accuracy of radiographic modalities, it might be an option to perform therapeutic surgery without a definitive diagnosis for selected patients with suspected lung cancer based on the findings of diagnostic imaging. Between April 2008 and December 2012, all nodules without a definitive diagnosis were classified into five categories according to the probability of lung cancer based on the diagnostic imaging: Category 1 (Benign), Category 2 (Probably benign), Category 3 (Intermediate), Category 4 (Suspected malignancy) and Category 5 (Highly suggestive of malignancy). In this study, the 232 surgical candidates for suspected clinical stage I lung cancer without a preoperative definitive diagnosis were considered to be Category 3 (n = 29), Category 4 (n = 46) and Category 5 (n = 157). Eighty-two patients (72% of Category 3, 46% of Category 4 and 25% of Category 5) had an intraoperative diagnosis during surgery, whereas the remaining 150 patients did not. The final pathological diagnosis and surgical outcomes were analysed. The final pathological diagnosis of the 232 suspicious nodules revealed 214 lung cancers (52% of Category 3, 93% of Category 4 and 99% of Category 5). Wedge resection was performed for all seven benign tumours. In the multiple regression analysis, intraoperative diagnosis was a significant factor for the length of the operation. In the multivariate logistic regression analysis, the length of the operation was a significant factor predicting both the postoperative morbidity and a prolonged hospital stay. Based on a careful clinical decision made using the current diagnostic imaging strategies, patients with a high probability of lung cancer are good candidates for therapeutic surgery, even without a preoperative or intraoperative definitive diagnosis.

Survival analysis following early surgical success in intermittent exotropia surgery.

To assess the consecutive recurrence following early success of intermittent exotropia surgery and to determine the clinical factors that affect the survival. One hundred and thirty-five patients who underwent intermittent exotropia surgery and experienced early surgical success [≤5 prism diopters (PD) esophoria (E) to ≤10 PD exophoria (X) on the postoperative sixth month] were enrolled in this study. Their consecutive survival on the postoperative first year, second year and third year and at the last visit of fourth year or more, and the factors that might affect their survival, were analyzed. The final surgical outcomes after the postoperative fourth year were also investigated by dividing the patients into the success group (≤5 PD E to ≤10 PD X) and the failure group (>5 PD esodeviation or >10 PD exodeviation). The survival rates from the Kaplan-Meier analysis were 97.78%, 92.89%, 83.70% and 50.49% on the postoperative first, second and third years and fourth year or more, respectively. None of the clinical factors was determined to have affected the survival. The amount of the exodrift was largest (2.29 PD) between the first year and the second year, and smallest (1.47 PD) between the fourth year and the last visit. Sixty-three patients had their final visit after the postoperative fourth year, and 29 of them were in the failure group. Twenty-five patients in the failure group had an intermittent exotropia (IXT) of <20 PD with good to fair distant fusion; two had an IXT of <20 PD with poor distant fusion; one had an IXT of ≥20 PD with fair distant fusion; and another had delayed-onset consecutive esotropia. The exodeviation on the postoperative sixth month was smaller in the success group than in the failure group (2.81 PD vs 5.86 PD, P=0.012). The reoperation rate for recurrent IXT was 3.7%. The survival rate steadily decreases with the exodrift, but the amount of the exodrift decreases with long-term follow-up. The final outcomes demonstrate favorable results via surgical success or small-angle IXT with good fusion in most of the patients. A smaller deviation on the postoperative sixth month is associated with long-term survival.

Atypical ductal hyperplasia diagnosed at sonographically guided core needle biopsy: frequency, final surgical outcome, and factors associated with underestimation.

The purposes of this article were to review the mammographic and sonographic features of breast masses yielding atypical ductal hyperplasia (ADH) at sonographically guided biopsy, evaluate the surgical pathology outcome of these lesions, and determine whether clinical or imaging features can be used to predict upgrade to malignancy. Among 6325 sonographically guided biopsies (2003- 2010) (14-gauge cores), 56 yielded the diagnosis of ADH (0.9%). Six patients were excluded (lost to follow-up). Fifty lesions were surgically excised in 45 patients. Mammographic and sonographic features were analyzed in consensus by two radiologists using the BI-RADS lexicon. Forty-five patients (mean age, 56 years; 12 < 50 years; six with synchronous breast carcinoma) had 50 ADH lesions (median size, 0.6 cm). Surgical excision yielded malignancy in 28 cases (56% underestimation rate). Among 42 mammograms (47 lesions), 30 lesions were identified (30/47, 64%) as masses (12/30, 40%), asymmetric densities (10/30, 33%), microcalcifications (4/30, 13%), and architectural distortions (4/30, 13%). Sonographically, most lesions appeared as hypoechoic masses (64%, 30/47) with irregular shape (51%, 24/47), microlobulated margins (49%, 23/47), no posterior acoustic feature (25/47, 53%), abrupt interface (70%, 33/47), and parallel orientation (57%, 27/47). No mammographic and sonographic features were associated with malignant outcome, whereas age less than 50 years (p = 0.03) and synchronous malignancy (p = 0.03) were associated with malignant outcome. ADH diagnosed at sonographically guided 14-gauge core needle biopsy shows a high underestimation rate. Synchronous carcinoma or age less than 50 years is associated with malignant outcome.