Good Surgical Candidates Research Articles

Pre- and Post-injection Pain in Patient's Undergoing First Intracavernosal Injection

ABSTRACT Introduction Intracavernosal injections (ICI) are a well-established treatment option with great success rates for men with erectile dysfunction. Unfortunately, the anticipation of pain with injections remains a significant barrier to the use of ICI. Objective This study aims to utilize a standardized verbal pain scale to examine the perception of pre- and post-injection pain in men who are undergoing their first injection with an intracavernosal erectile agent. Thus, inclusion criteria required no previous penile injection of any type, including but not limited to erectile medications and collagenase. Methods We determined a prospective pre-post observational study would be best to examine men undergoing their first ICI. Men who had no previous history of intracavernosal injection of any kind were asked to predict the pain associated with their first ICI with a score of zero to ten. Patients then received a 10 microgram (mcg) injection of prostaglandin E1 (PGE1). Immediately after they received their injection, they were asked to rate the pain they perceived with the injection on the same scale (0-10). The same physician administered pre- and post-injection scales in a standardized fashion. Results A total of 17 of men were asked to rate their pain as discussed in the Methods Section. The average age of men sampled was 61.8 years of age. On review of history, 64.7% of men were found to have used some type of PDE-5 inhibitor before visiting our clinic. The majority of men we saw had erectile dysfunction (70.6%) and/or Peyronie's Disease (58.8%). The average pre-injection prediction pain score was 5.29 +/- 1.90; the average post-injection perceived pain score was 1.21 +/- 0.81. Thus, there was an average decrease of over 4 points in predicted pain versus perceived pain. A two-sample t-test was performed; in addition, a Wilcoxson Signed Rank Test was performed. Both of these tests showed statistical significance in the difference between pre- and post-injection pain scores (p <0.001). Conclusions We found that patients who are undergoing ICI for their first time have a significantly higher prediction of pain versus perception of pain after the injection. We have utilized this data in our clinic to explain to patients that while the majority of patients predict high pain scores associated with injection, the vast majority of patients report very minimal pain associated with the injection. Patients can be more open-minded to ICI therapy which could help aid them with their erectile status; this can particularly be helpful in patients who want to avoid surgery and in patients who are not good surgical candidates. Disclosure No

Off-Label Use of Balloon Mitral Valvuloplasty in Nonrheumatic Mitral Stenosis With Severe Mitral Annular Calcification

Nonrheumatic mitral stenosis with mitral annular calcification (MAC) has been increasing in recent years owing to the aging population.1 Severe mitral stenosis has a high morbidity and mortality burden.1,2 The only definitive treatment for nonrheumatic mitral stenosis with MAC is surgical intervention.1,3 The aging population usually has other significant comorbidities; therefore, these patients are often not good surgical candidates. In addition, the presence of significant MAC increases the risk of surgical complications.

BRONCHIAL ARTERY EMBOLIZATION AS A THERAPEUTIC STRATEGY FOR MANAGEMENT OF MASSIVE HEMOPTYSIS

Background: Massive hemoptysis is an emergent and life-threatening condition with a high mortality rate. Bronchoscopy and MDCT scanning show significant contributing roles in delineating the etiology and the source of hemoptysis prior to bronchial artery arteriography.Aim of the work: To validate the role of the trans-catheter bronchial artery embolization in management of massive hemoptysis.Patients and Methods: Our study is a prospective cohort study that was held during the period between April 2017 and April 2019. The study included 20 patients who presented with massive hemoptysis refractory to supportive treatment measures with non-identifiable source of bleeding on fiber-optic bronchoscope. Patients were referred from chest department to angio unit.Results: Our findings are in accordance with the current literature supporting bronchial artery embolization as a safe and long-term non-invasive effective method of treatment for massive hemoptysis with a high initial rate of success. BAE may help to avoid surgery in patients who are not good surgical candidates. If hemoptysis recur in these patients, embolization can be safely performed with good response rate. If surgery is indicated, BAE can stabilize the patient prior to surgery.Conclusion: Advancements in angiographic equipment and technique continue to improve success rates, and with careful technique, it can be performed safely and with minimal risk. Embolization distal to the spinal artery may significantly decrease the number of complications and may allow a more thorough embolization.

Topical 5% 5-fluorouracil versus procedural modalities for squamous cell carcinoma in situ and superficial basal cell carcinoma: A retrospective cohort analysis

To the Editor: The topical chemotherapeutic agent 5-fluorouracil (5-FU) is commonly used to treat squamous cell carcinoma in situ (SCCIS) and superficial basal cell carcinoma (sBCC).1 For patients who wish to avoid procedures or are not good surgical candidates, 5-FU may be a preferred treatment option. It is less expensive than some procedures and other topicals (ie, imiquimod).2 The reported success rates of 5-FU for SCCIS and sBCC range from 27% to 90%.3 Additional investigation is needed to understand whether topical 5-FU, under real-world conditions, has comparable treatment success to procedures for epidermally-limited keratinocyte carcinomas.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction.

Gastric outlet obstruction (GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum. GOO can be caused by either benign or malignant etiologies, often resulting in early satiety, nausea, vomiting and poor oral intake. GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies. Traditional treatment options for GOO can be broadly divided into surgical [surgical gastrojejunostomy (GJ)] and endoscopic interventions (dilation and/or placement of luminal self-expanding metal stents). While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting, it has also been associated with a higher rate of adverse events. Furthermore, many patients with advanced metastatic disease are not good surgical candidates. More recently, endoscopic ultrasound (EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches. This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy

BackgroundWhile percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis. MethodsPatients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment. ResultsA total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001). ConclusionAlthough patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.

Conventional radiofrequency ablation of the articular sensory branches of the obturator and femoral nerves under fluoroscopic guidance for chronic hip joint pain in a case of ankylosing spondylitis

Chronic hip pain is often a debilitating problem, especially ankylosing spondylitis (AS), and few patients with the problem are not good surgical candidates. Hence, other conservative approaches should be used. We report the case of a 37-year-old male, a known case of AS, who presented with severe hip pain along with other joint involvements. The hip joint pain was managed with radiofrequency (RF) ablation of the articular sensory branches of the hip joint after initially tested with positive diagnostic block. This case emphasizes the role of RF ablation as a safe alternative to hip replacement.

GATOR1-related focal cortical dysplasia in epilepsy surgery patients and their families: A possible gradient in severity?

Variants of GATOR1-genes represent a recognised cause of focal cortical dysplasia (FCD), the most common structural aetiology in paediatric drug-resistant focal epilepsy. Reports on familial cases of GATOR1-associated FCD are limited, especially with respect to epilepsy surgery outcomes. We present phenotypical manifestations of four unrelated patients with drug-resistant focal epilepsy, FCD and a first-degree relative with epilepsy. All patients underwent targeted gene panel sequencing as a part of the presurgical work up. Literature search was performed to compare our findings to previously published cases. The children (probands) had a more severe phenotype than their parents, including drug-resistant epilepsy and developmental delay, and they failed to achieve seizure freedom post-surgically. All patients had histopathologically confirmed FCD (types IIa, IIb, Ia). In Patient 1 and her affected father, we detected a known pathogenic NPRL2 variant. In patients 2 and 3 and their affected parents, we found novel likely pathogenic germline DEPDC5 variants. In family 4, we detected a novel variant in NPRL3. We identified 15 additional cases who underwent epilepsy surgery for GATOR1-associated FCD, with a positive family history of epilepsy in the literature; in 8/13 tested, the variant was inherited from an asymptomatic parent. The presented cases displayed a severity gradient in phenotype with children more severely affected than the parents. Although patients with GATOR1-associated FCD are considered good surgical candidates, post-surgical seizure outcome was poor in our familial cases, suggesting that accurate identification of the epileptogenic zone may be more challenging in this subgroup of patients.

Management of Chronic Low Back Pain: Review of Fluoroscopy-Guided Epidural Steroid Injection

Chronic low back pain point prevalence in US adults ages 20‐69 years is approximately 13.1%. It is estimated that approximately 12%‐15% of visits to health care providers in the United States are related to low back pain and is considered as an economic burden, not only due to the loss of work productivity but also due to direct health care costs, with an estimated median treatment cost of approximately $13,015 per quality-adjusted life year. Even with well-selected patients, the surgical outcome in patients with low back pain may vary. Conservative management by using physical therapy and rehabilitation is considered an equally good alternative option for patients with chronic low back pain. Percutaneous minimally invasive pain-alleviating spinal procedures are helpful for patients who do not have a compelling indication for surgical intervention, who are not good surgical candidates due to their associated comorbidities, and who cannot tolerate the oral pain medications in the required doses. Percutaneous minimally invasive pain-alleviating spinal procedures are increasingly popular due to increasing patient awareness of alternative treatment options and also the skepticism about the cost-effective role of spinal surgery for pain. In this article, we provide a basic review of relevant anatomy, preprocedure assessment, and techniques for most commonly used percutaneous image-guided spinal epidural procedures and briefly discuss the potential complications.Learning Objectives: To describe relevant spinal anatomy; to provide a brief illustration of basic techniques and approaches for spinal pain control procedures and regional anesthesia; and to discuss predisposing factors, pathophysiology, and imaging features of associated complications.

When to Say When-Reasons to Abort Surgery for Congenital Aural Atresia.

To determine reasons for premature termination in surgery for congenital aural atresia (CAA). Retrospective chart review. High-volume tertiary care center. Patients undergoing primary surgical repair of CAA whose surgeries were aborted for various indications. Patients with CAA who underwent elective aural atresia surgery at the University of Virginia from July 2004 to January 2020 were identified from the medical record and an institutional database of patients with CAA. Patients undergoing revision surgery or surgery not for hearing correction were excluded. All included candidates were noted to be good surgical candidates for atresia repair based on preoperative Jahrsdoerfer score of 6 or greater. Reasons for terminating surgery prematurely were categorized by anatomical constraints (inability to identify middle ear space, position of the facial nerve, or other anatomic abnormality), stapes fixation, and middle ear and/or mastoid inflammatory disease. Reasons for premature termination in CAA surgery. Over the interval, 319 patients underwent primary surgery for CAA. Surgery was terminated prematurely without completing the primary objective in 14 patients (4.4%); surgery was terminated in 8 (57%) due to anatomic constraints, 4 (29%) due to stapes fixation, and 2 (14%) due to middle ear space and/or mastoid inflammatory disease. Premature termination in surgery for CAA is a rare occurrence with careful study of the preoperative high-resolution computed tomography of the temporal bone. Of the reasons for premature termination, anatomic constraints were the most common. Knowing limitations in surgery-both technical and anatomic-is critical to optimize outcomes and prevent complications.

Epilepsy Surgery

Abstract INTRODUCTION Surgical resection can offer select patients with refractory epilepsy seizure freedom in 50–70% of cases. However, surgery remains highly underutilized. Understandably, undergoing brain surgery can be intimidating and many good surgical candidates ultimately decline surgery. Therefore, it is necessary to understand the factors most important to patients in their decision to undergo or decline surgery. In this study we sought to identify those factors and shed light onto patient's decision-making process. METHODS We surveyed 16 patients with history of seizures undergoing monitoring in our epilepsy monitoring unit. The survey was limited to surgery naïve patients. We developed a novel rank list questionnaire that addressed a variety of potential social, economic, medical, and personal factors. Patients were asked to rank the factors in order of importance to their decision making regarding undergoing brain surgery if offered as a treatment option for their epilepsy. RESULTS The average age of those surveyed was 42 and average age of seizure onset was 24. Frequency of seizures ranged from none to 7 per day. Nine patients were currently taking 1 antiepileptic medication, and seven were taking 2 or more medications. On average patients had tried and discontinued approximately 3 other medications. Among the factors that patients considered most important when deciding on surgery were the likelihood of seizure freedom, ability to again drive, and likelihood of complications such as motor, sensory, speech and memory deficits. Factors considered least important included time commitment and discomfort associated with surgery. CONCLUSION Surgical intervention can offer well selected patients a relatively high likelihood of seizure freedom that can significantly improve their quality of life. However, about 30–40 percent of surgical candidates declined surgery. Gaining a better understanding of the factors that play an important role in patient's decision making regarding surgical management of their epilepsy can empower their provider to address and mitigate those concerns.

Minimally invasive partial versus total adrenalectomy for unilateral primary hyperaldosteronism-a retrospective, multicenter matched-pair analysis using the new international consensus on outcome measures

BackgroundPrimary hyperaldosteronism is a recognized risk factor for myocardial infarction, stroke, and atrial fibrillation. Minimally invasive adrenalectomy is the first-line treatment for localized primary hyperaldosteronism. Whether minimally invasive adrenalectomy should be performed using a cortex-sparing technique (partial minimally invasive adrenalectomy) or not (total minimally invasive adrenalectomy) remains a subject of debate. The aim of our study was to evaluate the clinical and biochemical efficacy of both procedures and to examine the morbidity associated with partial minimally invasive adrenalectomy versus total minimally invasive adrenalectomy in a multicenter study. MethodsUsing a retrospective study design, we determined the efficacy, morbidity, and mortality of partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy. The Primary Aldosteronism Surgical Outcome Study classification was used to explore clinical and biochemical success. Matched-pair analysis was used in order to address possible bias. ResultsWe evaluated 234 matched patients with unilateral primary hyperaldosteronism: 78 (33.3%) underwent partial minimally invasive adrenalectomy, and 156 (66.7%) were treated with total minimally invasive adrenalectomy. Complete clinical success was achieved in 40.6%, and partial clinical success in an additional 52.6% of patients in the entire cohort. Complete biochemical success was seen in 94.0% of patients. Success rates and the incidence of perioperative complications were comparable between groups. Both postoperative hypocortisolism (11.5% vs 25.0% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy, respectively; P < .001) and postoperative hypoglycemia (2.6% vs 7.1% after partial minimally invasive adrenalectomy and total minimally invasive adrenalectomy; P = .039) occurred more frequently after total minimally invasive adrenalectomy. ConclusionOur study provides evidence that patients with unilateral primary hyperaldosteronism are good surgical candidates for partial minimally invasive adrenalectomy. Not only is the surgical outcome comparable to that of total minimally invasive adrenalectomy, but also postsurgical morbidity, particularly in terms of hypocortisolism and hypoglycemia, may be reduced.

Association between spleen volume and the post-hepatectomy liver failure and overall survival of patients with hepatocellular carcinoma after resection.

Post-hepatectomy liver failure (PHLF) can occur as a major complication after hepatic resection (HR) in patients with hepatocellular carcinoma (HCC) and negatively affects the prognosis. We aimed to retrospectively assess whether the spleen volume (SV) measured from preoperative CT images would be associated with the development of PHLF and overall survival (OS) after HR in patients with HCC. We enrolled 317 consecutive patients with very early/early stage HCC who underwent a preoperative CT and HR between January 2010 and December 2016. The SV was obtained from preoperative CT images using semi-automated volumetric software and was divided by body surface area to yield SVBSA. Receiver operating characteristic (ROC) curves and logistic regression analyses were performed to identify factors affecting the development of PHLF. The Cox proportional hazard model was used to identify prognostic factors for OS. PHLF was observed in 72 patients (22.7% [72/317]). SVBSA was associated with the development of PHLF (odds ratio, 2.321; 95% CI, 1.347-4.001; p = 0.002) with the area under the ROC curve of 0.663 using the cutoff value of 107.5 cm3 (p < 0.001). SVBSA was also an influencing factor for OS (hazard ratio, 3.935; 95% CI 1.520-10.184; p = 0.005), with the optimal cutoff of 146 cm3. The 5-year OS rate was higher in 245 patients with a SVBSA ≤ 146 cm3 than in 72 patients with a SVBSA > 146 cm3 (95.0% vs. 78.7%, p < 0.001). In patients with HCC, a larger SVBSA was associated with a higher rate of PHLF and worse OS after HR. The SVBSA may be useful in selecting good surgical candidates. • A significantly higher spleen volume divided by body surface area was observed in patients who experienced post-hepatectomy liver failure than in patients who did not (148 cm3 vs. 112 cm3, p < 0.001). • The area under the receiver operating characteristic curve of spleen volume divided by body surface area to predict the development of post-hepatectomy liver failure was 0.663 (p < 0.001). • Spleen volume divided by body surface area was a significant influencing factor for overall survival (hazard ratio, 3.935; 95% CI, 1.520-10.184; p < 0.001), with the optimal cutoff of 146 cm3.

Radiofrequency Ablation Through Previously Effective Deep Brain Stimulation Leads for Parkinson Disease: A Retrospective Series

Although deep brain stimulation (DBS) of the subthalamic nucleus (STN) or globus pallidus internus (GPi) is the surgical method of choice to treat the canonical symptoms of Parkinson disease, occasionally surgical sites become infected or the hardware erodes, necessitating explantation. Usual practice is to remove and reimplant replacement leads after tissue healing, leaving patients without the clinical benefits of DBS for several months, and at risk for DBS withdrawal in some, and some patients are no longer good surgical candidates for reimplantation. Radiofrequency ablation through the DBS lead is an option for these patients. We performed a retrospective chart review of all patients who underwent radiofrequency ablation of the STN or GPi through indwelling DBS leads performed before hardware removal at our institution. We generated patient-specific anatomic models to determine lesion locations and volumes. Six patients underwent radiofrequency ablation of the STN (n= 4) and GPi (n= 2) through indwelling DBS leads. All 6 of these patients initially showed comparable motor symptom relief to that experienced with DBS before lesioning, with 4 patients sustaining meaningful long-term (≥2 years) improvement. Better outcomes were achieved in those patients with a higher percentage of the planned target lesioned. Radiofrequency ablation through indwelling DBS leads before explantation could be considered a viable alternative to subsequent reimplantation or stereotactic lesion in patients with Parkinson disease in whom hardware explantation is necessary, if the patient achieved substantive symptom relief with DBS. This approach avoids symptom exacerbation while awaiting revision surgery.

Lobectomy Versus Stereotactic Body Radiotherapy in Healthy Octogenarians With Stage I Lung Cancer

Stereotactic body radiation therapy (SBRT) is increasingly being offered for early stage non-small cell lung cancer (NSCLC). We sought to evaluate long-term survival outcomes after lobectomy and SBRT in patients aged 80 years or more with stage I NSCLC. The National Cancer Database was queried for patients with clinical stage IA and IB (size 40 mm or smaller) NSCLC who underwent SBRT or lobectomy. Only patients with no comorbidities were selected. Number of lymph nodes (LN) examined was used to stratify lobectomy patients into 0 LN, 1 to 6 LN, and 7 or more LN. Propensity score analysis was used to adjust treatment groups. Kaplan-Meier and multivariate Cox regression analysis were used for survival analysis. A total of 8964 patients with stage I NSCLC treated with lobectomy were compared with 286 patients who received SBRT. Using propensity matched pairs, lobectomy (7 LN or more) had significantly improved survival as compared with SBRT (median 74 vs 53.2 months, P < .05); however, no survival differences were observed when 0 LN were sampled (median 53.8 vs 52.3 months, P= .88). In multivariate analysis, lobectomy was associated with significantly improved survival (hazard ratio 0.726; 95% confidence interval; 0.580 to 0.910; P= .005). In addition, age, sex, high grade, and tumor size were independent predictors of survival. Among healthy octogenarians with clinical stage I NSCLC who are good surgical candidates, lobectomy offers better survival than SBRT. Adequate LN dissection allows true nodal staging and opportunity for adjuvant treatment when unsuspected nodal metastases are found.

211. Complications and outcomes in small vs large surgeries for ASD?

BACKGROUND CONTEXT Traditionally, adult spinal deformity (ASD) has been treated with long segment fusions with the goal of restoring sagittal and coronal alignment. Long segment fusions can be associated with high rates of complications and morbidity. Some patients are reluctant to undergo large procedures. Others have comorbidities excluding them as good surgical candidates for long fusions. PURPOSE To compare baseline and postoperative HRQL and radiographic outcomes and revisions and complications in small vs longer fusions for ASD. STUDY DESIGN/SETTING Retrospective analysis of a prospective, multicenter database PATIENT SAMPLE Surgical ASD patients OUTCOME MEASURES ODI, SF36-PCS, SRS22, NRS back and leg pain. METHODS A prospective database of operative ASD patients who completed two year follow up was analyzed. Prior thoracolumbar fusions were excluded. Patients were divided into short fusions (SF: £3 levels) and long fusions (LF: ³6 levels). LF and SF patients were compared in baseline alignment. Propensity matching (PSM) controlling for baseline alignment (TPA and maximum coronal cobb) was performed to compare SF and LF in HRQL improvement, postop alignment and complications. Subanalysis of SF identified which patients were more likely to have successful surgery. The level of significance was p RESULTS A total of 298 patients met inclusion criteria (SF n=20, mean levels fused 2.13; LF n=275, mean fusion levels 12.33). Prior to PSM, LF had greater PT, coronal cobb, and TPA. Following PSM, LF had better improvements in PILL (20.8 vs 3.37), PT (8.57 vs 0.21), TPA (8.68 vs 2.07), and coronal cobb (17.3 vs 5.33) all p CONCLUSIONS This study shows that a more limited fusion could be an alternative to the more traditional long segment fusion in carefully selected patients with adult spinal deformity since there were fewer complications but similar short-term (2-year) satisfaction rates and HRQL improvements. Patients undergoing long fusions had better improvements in alignment. The majority of sagittal only deformities undergoing short fusions required revision surgery. The durability of short fusions in the setting of ASD needs to be investigated with long term studies. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Pre-operative gastrocnemius lengths in gait predict outcomes following gastrocnemius lengthening surgery in children with cerebral palsy.

Equinus deformity is one of the most common gait deformities in children with cerebral palsy. We examined whether estimates of gastrocnemius length in gait could identify limbs likely to have short-term and long-term improvements in ankle kinematics following gastrocnemius lengthening surgery to correct equinus. We retrospectively analyzed data of 891 limbs that underwent a single-event multi-level surgery (SEMLS), and categorized outcomes based on the normalcy of ankle kinematics. Limbs with short gastrocnemius lengths that received a gastrocnemius lengthening surgery as part of a SEMLS (case limbs) were 2.2 times more likely than overtreated limbs (i.e., limbs who did not have short lengths, but still received a lengthening surgery) to have a good surgical outcome at the follow-up gait visit (good outcome rate of 71% vs. 33%). Case limbs were 1.2 times more likely than control limbs (i.e., limbs that had short gastrocnemius lengths but no lengthening surgery) to have a good outcome (71% vs. 59%). Three-fourths of the case limbs with a good outcome at the follow-up gait visit maintained this outcome over time, compared to only one-half of the overtreated limbs. Our results caution against over-prescription of gastrocnemius lengthening surgery and suggest gastrocnemius lengths can be used to identify good surgical candidates.

The Adoption of Ultrasound-guided Radiofrequency Ablation of Thyroid Nodules in the United States.

The Adoption of Ultrasound-guided Radiofrequency Ablation of Thyroid Nodules in the United States.

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3034 Acute Pancreatitis in a Patient With a Choledochal Cyst

INTRODUCTION: Biliary cysts, also called choledochal cysts, are cystic dilatations that may occur singly or in multiples throughout the biliary tree. Cysts may be congenital or acquired and have been associated with a variety of anatomic abnormalities. The incidence of biliary cysts in Western populations has been estimated to be 1:100,000 to 1:150,000. Biliary cysts are associated with an increased risk of cholangiocarcinoma, pancreatic cancer, and gallbladder cancer. Malignancy is more common in patients who are older and in those with Type I and II cysts. As such, surgical resection is necessary. Due to stasis of bile flow in the cyst, other well-known complications include choledocholithiasis and pancreatitis. CASE DESCRIPTION/METHODS: A 35-year old woman presented to the ED with epigastric pain and lipase elevation to 700. She reported a history of a congenital hepatic cyst and previous history of cholecystectomy as a child. Over the last 2 years, she had been admitted to other hospitals for similar complaints. Initial ultrasound of the abdomen revealed common bile duct (CBD) dilatation to 2.3 cm with a filling defect of 1.5 cm. MRCP showed intra- and extra-hepatic dilatation and confirmed evidence of a filling defect in the CBD concerning for multiple intraductal and intracystic stones. The patient was conservatively managed while in the hospital and was discharged with close outpatient follow up. The following week, she underwent a Roux-en-Y hepaticojejunostomy. She was found to have a Type 1c choledochal cyst and an abnormal pancreaticobiliary junction. DISCUSSION: The approach to management of patients with biliary cysts depends on the cyst type. Patients with Type I, II, or IV cysts usually undergo surgical resection of the cysts due to the significant risk of malignancy, provided they are good surgical candidates. Type I and IV cysts should be completely resected with creation of a Roux-en-Y hepaticojejunostomy. The presence of an abnormal pancreaticobiliary junction (APBJ) increases the risk of malignancy, especially gallbladder cancer. Our patient had already had a cholecystectomy as a child. Patient continued to do well post-operatively without recurrence of her symptoms.