Inadvertent Surgery Research Articles

1187 A Study of Outcomes in Patients with Gastrointestinal Tract Lymphomas Who Require Inadvertent Surgery

Abstract Aim Patients may present with acute surgical symptoms from their lymphoma. We aimed to study postoperative outcomes and 3-year overall survival in patients who had inadvertent surgery as primary management of their gastrointestinal tract lymphomas. Method Suitable patients were identified using electronic records from January 2013 to December 2022. Demographics, clinicopathological characteristics and survival outcomes of these patients were collected retrospectively. Results A total of 25 patients were identified. The most common clinical symptom was abdominal pain (n = 18, 72%) with demonstration of an obstruction (n = 16, 64%) or perforation (n = 4, 16%) by a mass on CT scan. Small bowel was the most common site, followed by colon and stomach (55%, 24% and 21% respectively) Diffuse large B-cell lymphoma was the most common subtype (66.7%). Immunohistochemistry revealed B-lymphocyte antigen CD20 to be positive in most patients (n = 17, 68%) and Ki 67% to be high (>70%) in a third (n = 8, 32%). Upon discharge, two thirds of patients were well enough to have systemic chemotherapy (n = 19, 76%). Two patients died from surgical complications while the rest succumbed to disease progression (n = 10, 76%). The overall 3-year survival rate was 56%. Conclusions Patients with gastrointestinal tract lymphoma who do not die in the postoperative period after inadvertent surgery are likely to be alive at 3 years with the use of systemic chemotherapy.

The Importance of Awaiting Biopsy Results in Solitary Pathological Proximal Femoral Fractures

BackgroundThe optimal surgical treatment for patients presenting with (impending and complete) pathological proximal femoral fractures is predicated on prognosis. Guidelines recommend a preoperative biopsy to exclude sarcomas, however no evidence confirms a benefit.ObjectiveThis study aimed to describe the diagnostic accuracy, morbidity and sarcoma incidence of biopsy results in these patients.Material and MethodsAll patients (n = 153) presenting with pathological proximal femoral fractures between 2000 and 2019 were retrospectively evaluated. Patients after inadvertent surgery (n = 25) were excluded. Descriptive statistics were used to evaluate the accuracy and morbidity of diagnostic biopsies.ResultsOf 112/128 patients who underwent biopsy, nine (8%) biopsies were unreliable either due to being inconclusive (n = 5) or because the diagnosis changed after resection (n = 4). Of impending fractures, 32% fractured following needle core biopsy. Median time from diagnosis to surgery was 30 days (interquartile range 21–46). The overall biopsy positive predictive value (PPV) to differentiate between sarcoma and non-sarcoma was 1.00 (95% confidence interval [CI] 0.88–1.00). In patients with a previous malignancy (n = 24), biopsy (n = 23) identified the diagnosis in 83% (PPV 0.91, 95% CI 0.71–0.99), of whom five (24%) patients had a new diagnosis. In patients without a history of cancer (n = 61), final diagnosis included carcinomas (n = 24, 39.3%), sarcomas (n = 24, 39.3%), or hematological malignancies (n = 13, 21.3%). Biopsy (n = 58) correctly identified the diagnosis in 66% of patients (PPV 0.80, 95% CI 0.67–0.90).ConclusionThis study confirms the importance of a preoperative biopsy in solitary pathological proximal femoral fractures due to the risk of sarcoma in patients with and without a history of cancer. However, biopsy delays the time to definite surgery, results can be inconclusive or false, and it risks completion of impending fractures.

Multimodality imaging evaluation of pseudotumors in chronic renal dysfunction: exposing the masquerade!

Focal renal lesions in the background of chronic kidney disease (CKD) present a diagnostic challenge. Contrast administration is usually avoided in such a setting, undermining the usefulness of computed tomography and magnetic resonance imaging. Focal regenerating nodules may occur in the background of CKD and closely mimic renal neoplasms. The aim of the present article was to highlight the salient manifestations of such CKD pseudotumors on different imaging modalities and also to depict the differentiating features from malignancy. Radiologists must be aware of the imaging appearance of this uncommonly talked about entity so as to avoid inadvertent surgery or cause undue anxiety to the patient.

Pre-operative testing for SARS-CoV-2 and outcomes in otolaryngology surgery during the pandemic: A multi-center experience.

IntroductionPreoperative testing for COVID‐19 has become widely established to avoid inadvertent surgery on patients with COVID‐19 and prevent hospital outbreaks.MethodsA prospective cross sectional study was carried out in two university hospitals examining the pre‐operative protocols for patients undergoing otolaryngology surgery and the incidence of COVID‐19 within 30 days of surgery in patients and the otolaryngologists performing surgery.ResultsOne hundred and seventy‐three patients were recruited. One hundred and twenty‐three (71%) patients “cocooned” for 14 days prior to surgery. All completed a questionnaire prior to admission. One hundred and fifty‐six patients (90%) had reverse transcriptase‐polymerase chain reaction (RT‐PCR) nasopharyngeal swabs, 14 patients (8%) had CT thorax. No cases of COVID‐19 were detected among patients followed up at 30 days. Two surgeons developed COVID‐19 early during the study period.ConclusionCurrent pre‐operative testing protocols consisting primarily of questionnaires and RT‐PCR resulted in zero cases of COVID in this cohort. It is possible that COVID‐19 restrictions and high proportion of patients cocooning preoperatively were factors in ensuring a low rate of COVID‐19 post‐operatively.

Should Older Cancer Patients be Tested for Coronavirus-19 Disease Before Treatment: Recommendation of the International Geriatric Radiotherapy Group

During the coronavirus 19 disease (COVID-19) pandemic, older patients are disproportionately affected with a higher death rate compared to younger patients because of the presence of co-morbidity. The likelihood of dying is even higher among older cancer patients who get infected [1]. As COVID-19 patients may be asymptomatic, inadvertent surgery for cancer has been reported [2]. Thus, it raises a serious issue whether older cancer patients should be tested for COVID-19 before any type of treatment such as chemotherapy or radiotherapy which may further depress their immune system and may accelerate their demise. This issue is particularly important as resources of most countries are limited. Older cancer

Endoscopic diagnosis of pancreatic cysts.

Pancreatic cystic lesions (PCLs) are increasingly identified on abdominal imaging. Given the malignant potential of certain cyst subtypes and the poor survival rates of pancreatic cancer, accurate diagnosis and appropriate management of these cysts are critical. Advances in endoscopic ultrasound (EUS)-guided diagnostics have increased the accuracy of differentiating PCLs. These include cyst fluid molecular analysis, EUS-guided needle-based confocal laser endomicroscopy, and EUS-guided through the needle microforceps biopsy. This review encapsulates recent advances in the endoscopic management of PCLs with a specific focus on EUS-guided diagnosis. It is important to accurately diagnose pancreatic cystic lesions with malignant potential where the definitive management is surgical resection. Misdiagnosis can result in inadvertent surgery of an otherwise benign lesion or malignant progression of a precancerous cyst. Moreover, pancreatic surgery is associated with significant morbidity and mortality. Recent advances in EUS-guided tissue acquisition, imaging, and molecular biomarkers have resulted in improved diagnostic accuracy of pancreatic cystic lesions. Future studies need to define efficient and accurate diagnostic algorithms for improved management of pancreatic cysts.

319P Choriocarcinoma: A 10 year tertiary care cancer hospital experience

Background Gestationalchorio-carcinomasarehighlymalignanttumorsof trophoblastic tissue occuring during or after pregnancy. Very little data is available in Pakistan. Methods Patients diagnosed as choriocarcinoma managed at Shaukat Khanum Cancer hospital, Lahore, Pakistan from 2005 to 2015 were included. Data was recorded on age, risk scoring, pre and post-operative B-human chorionic gonadotropins (B-hCG) levels, treatment, type and number of chemotherapy cycles, type of surgery and overall survival(OS).OSbyKaplanMeiermethodwastheintervalbetweenthedateof diagnosis and last visit/death. Results Thirty eight patients with choriocarcinoma with median age of 25 years were included. Using FIGO staging, stage 1 was identified in 7, II in 1, III in 14, IV in 8 and unknown in 8 patients respectively. Pre-treatment Beta-hCG ranged from 28 to 921000 ug/l. Twenty-seven patients (71.0%) had high risk category, 7 (18.4%) in medium risk and 4 (10.5%) had low risk. EMA-CO was the most common initial regimen (35 patients). Four patients, as non-responders to EMA-CO, were later on treated by EP-EMA protocol. Median number of chemotherapy cycles was 6.Mean time to normalization ofBeta-hCGwas 7.26 + 2.24 weeks. Thirtythree patients completedallchemotherapycycles.PosttreatmentBeta-hCGlevelsnormalizedinall patientsexceptfournonresponderstoEMA-CO;howeverdiseasewasnotcontrolled in these patients. Thirty three patients achieved complete response. Five patients expired, while 3 were lost to followup after treatment. Thirtyoutof38 patients werealiveatmedianfollowupof52months.MediansurvivalbyKaplanMeier method was yet not reached. Conclusions Choriocarcinoma is a curable malignancy and chemotherapy can achieve high cure rates and inadvertent surgery should be avoided in all cases unless deemed necessary. Legal entity responsible for the study Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Funding Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Disclosure All authors have declared no conflicts ofinterest.

Template-based high-dose-rate interstitial brachytherapy in gynecologic cancers: A single institutional experience

To report the outcome and toxicities of radical external beam radiotherapy (EBRT) and template-based high-dose-rate interstitial brachytherapy (ISBT) in patients diagnosed with cervical cancer undergoing inadvertent surgery, vault cancers, and vaginal cancers at our institution. Between January 2000 and December 2008, 113 patients (37patients of cervical cancer post-inadvertent surgery, 57 patients with vault cancers, and 19 patients with primary vaginal cancers) were treated with Martinez Universal Perineal Interstitial Template brachytherapy boost after EBRT. The median EBRT dose was 50Gy, median ISBT dose was 20Gy, whereas median total dose was 73Gy equivalent dose at 2Gy per fraction in all three groups. Median followup of surviving patients for the whole group was 43 months (interquartile range, 19-67 months). The 3-year actuarial disease-free survival and overall survival for three groups was 61%, 61%, 59% and 64%, 64%, and 56%, respectively. Grade III/IV rectal toxicity was seen in 11 (10%) patients, bladder toxicity in 5 (4.5%) patients, whereas 7 (6%) patients developed Grade III small bowel toxicity. Residual disease at brachytherapy had significant impact on DFS and OS. Other factors such as age, disease volume, parametrial extension, and vaginal extension did not impact the survivals. Martinez Universal Perineal Interstitial Template-based high-dose-rate ISBT boost in gynecologic cancer results in a reasonable outcome in terms of survivals with acceptable late toxicities. The use of template-based ISBT is associated with a definite learning curve.

MR features of primary and secondary malignant lymphoma of the pancreas: a pictorial review

ObjectiveTo describe the imaging findings of primary and secondary pancreatic malignant lymphoma on magnetic resonance imaging (MRI), to help differentiate lymphoma of the pancreas from primary adenocarcinoma and autoimmune pancreatitis among others, and to discuss a few atypical presentations of pancreatitis mimicking lymphoma.ConclusionKnowledge of these imaging manifestations of lymphoma may be helpful to arrive at an accurate diagnosis and avoid unnecessary morbidity and mortality from inadvertent surgery.Main Messages• Pancreatic malignant lymphoma is shown as a nodular low-density area with mild enhancement on CT.• It sometimes shows variable manifestations mimicking other tumours and inflammatory conditions.• MRI provides useful information for differentiating malignant lymphoma from other mimickers.

Prognostic effect of inadvertent curettage without treatment delay in osteosarcoma

Unplanned primary surgery has been known to have a negative prognostic impact in osteosarcoma. We identified 20 osteosarcoma patients that had undergone inadvertent surgery followed by adequate treatment without delay, and compared the clinicopathologic characteristics of these 20 case patients with those of 365 patients who underwent incisional biopsy. For survival analysis, 40 control patients matched for tumor size at presentation, tumor location, age and gender were selected from these 365 patients. Unusual initial clinicopathologic characteristics were frequently observed in the case patients, such as, an older age, a small tumor size, an unusual tumor location, and a lytic radiographic pattern. The 5-year overall survival rate in the case group was 89.4 +/- 7.1% and in the control group was 83.9 +/- 6.1%, and the 5-year event-free survival rate in the case group was 90.0 +/- 6.7% and in the control group was 76.8 +/- 6.8%. The log rank test revealed no survival difference between the case and control groups. As is the case for soft tissue sarcoma, inadvertent extensive curettage with no ensuing treatment delay was found to have no detrimental effect on overall- or event-free survival in osteosarcoma. Further study using a larger sample size is needed to confirm our results.

Primary hypothyroidism presenting as multiple ovarian cysts in an adult woman: A case report

A 21-year-old woman was referred because of abdominal pain. On physical examination, her abdomen was distended up to the umbilical region. Ultrasound and computer tomography of the abdomen revealed bilateral multiple ovarian cysts. Laboratory studies revealed increased liver function, total cholesterol and creatine phosphokinase. Further clinical investigations determined that the patient suffered from primary hypothyroidism due to autoimmune thyroiditis. The cysts resolved spontaneously after the simple replacement of a thyroid hormone. Some reports have been published of primary hypothyroidism presenting as ovarian cysts and precocious puberty in prepubertal girls. However, the case presented herein indicates that an ovarian tumor as a result of hypothyroidism may also occur in adult females. To avoid inadvertent surgery to remove an ovarian tumor, it is essential that a patient with multiple ovarian cysts and hypothyroidism be properly managed, as the simple replacement of a thyroid hormone could resolve the ovarian cysts.

Bilambdoid and posterior sagittal synostosis: the Mercedes Benz syndrome.

A consistent pattern of craniosynostosis in the sagittal and bilateral lambdoid sutures is described in three patients. The external cranial ridging associated with fusion of these sutures produces a characteristic triradiate, or "Mercedes Benz," appearance to the posterior skull. Locally marked growth restriction is evident in the posterior fossa with compensatory secondary expansion of the anterior fossa manifesting a degree of frontal bossing which mimics bicoronal synostosis. Although this appearance could lead to inadvertent surgery in the frontal region, attention to the occipital region with wide early suture excision and vault shaping is indicated.

Craniofacial Morphology in Unoperated Cleft Lip and Palate

SummaryCleft lip and palate patients have normal growth potential. Inadvertent surgery done in early childhood results in maxillary hypoplasia, which manifests in later life. Unoperated cleft lip and palate patients have normal craniofacial morphology when compared to controls of same age and sex, irrespective of the type of cleft. Lateral cephalometric analysis of craniofacial morphology in 22 cases of cleft lip and palate has been studied whose results are being presented.

Pancreatic Tuberculosis: A rare case

Pancreatic tuberculosis is an extremely rare condition, even in an endemic region like Nepal, and Confirming the diagnosis is even more difficult due to the difficulty in obtaining the pathological specimen. In this case report, we present a young male who was diagnosed with pancreatic tuberculosis and inadvertent surgery avoided following proper workup of the patient. Key words: tuberculosis; pancreas; ascites DOI: http://dx.doi.org/10.3126/mjsbh.v9i2.5025 Medical Journal of Shree Birendra Hospital Vol.9(2) 2010: 42-43