Surgical Treatment Planning Research Articles

Hepatic vessels segmentation using deep learning and preprocessing enhancement.

Liver hepatic vessels segmentation is a crucial step for the diagnosis process in patients with hepatic diseases. Segmentation of liver vessels helps to study the liver internal segmental anatomy that helps in the preoperative planning of surgical treatment. Recently, the convolutional neural networks (CNN) have been proved to be efficient for the task of medical image segmentation. The paper proposes an automatic deep learning-based system for liver hepatic vessels segmentation of Computed Tomography (CT) datasets from different sources. The proposed work focuses on the combination of different steps; it starts by a preprocessing step to improve the vessels appearance within the liver region of interest in the CT scans. Coherence enhancing diffusion filtering (CED) and vesselness filtering methods are used to improve vessels contrast and intensity homogeneity. The proposed U-net based network architecture is implemented with modified residual block to include concatenation skip connection. The effect of enhancement using filtering step was studied. Also, the effect of data mismatch used in training and validation is studied. The proposed method is evaluated using many CT datasets. Dice similarity coefficient (DSC) is used to evaluate the method. The average DSC score achieved a score 79%. The proposed approach succeeded to segment liver vasculature from the liver envelope accurately, which makes it as potential tool for clinical preoperative planning.

Narrow Single Implants with a Reduced Platform (3.0) for the Resolution of Punctual Horizontal Atrophies in the Canine and Premolar Area: Case Series

Introduction: Severe unitary atrophies in the horizontal direction make the direct insertion of dental implants difficult. Block grafting or guided bone regeneration in small sites is also complex, sometimes requiring a highly predictable option. The insertion of small-platform, low-diameter implants can be a safe and effective alternative for these sites, even on a single-unit basis. In the following article we present a series of cases rehabilitated with these implants. Material and Methods: Patients with horizontal atrophy of a tooth requiring the insertion of a single implant in the premolar and canine area were recruited, and 3 mm platform implants with a diameter of 3.3 mm were placed between May 2018 and December 2019 in a dental clinic in Vitoria, Spain. Marginal crestal bone loss was calculated by measuring from the implant shoulder to the first site where bone-to-implant contact was evident. The reference for comparing the radiographic records and thus estimating the bone loss produced in each of the patients was the radiograph taken at the time of prosthesis insertion. Qualitative variables were described by frequency analysis. Quantitative variables were described by means of mean and standard deviation. Implant survival was calculated using the Kaplan- Meier method. Result: Eight patients were recruited and eight 3.0 implants were placed in the canine and premolar region in a unitary form with a diameter of 3.3 mm. All implants were rehabilitated in a unitary form, in two phases, using a screw-retained prosthesis with unitary transepithelial. The mean follow-up time was 39.8 months (+/- 18). Survival of the implants studied was 100% and of the prostheses as well. The mean mesial crestal bone loss of the implants studied was 0.77 mm (+/- 0.01) and distal bone loss was 0.35 mm (+/- 0.7). Conclusions: Implants with a reduced diameter and platform can be used as a unit provided that a correct surgical and prosthetic treatment plan is followed, analysing the case as a whole and individualising the approach for each patient.

New trends in the surgical management of soft tissue sarcoma: The role of preoperative biopsy.

Soft tissue sarcoma (STS) accounts for 1% of all malignant neoplasms in adults. Their diagnosis and management constitute a challenging target. They originate from the mesenchyme, and 50 subtypes with various cytogenetic profiles concerning soft tissue and bones have been recognized. These tumors mainly affect middle-aged adults but may be present at any age. Half of the patients have metastatic disease at the time of diagnosis and require systemic therapy. Tumors above 3-5 cm in size must be suspected of potential malignancy. A thorough history, clinical examination and imaging that must precede biopsy are necessary. Modern imaging techniques include ultrasound, computed tomography (CT), new magnetic resonance imaging (MRI), and positron emission tomography/CT. MRI findings may distinguish low-grade from high-grade STS based on a diagnostic score (tumor heterogeneity, intratumoral and peritumoral enhancement). A score ≥ 2 indicates a high-grade lesion, and a score ≤ 1 indicates a low-grade lesion. For disease staging, abdominal imaging is recommended to detect early abdominal or retroperitoneal metastases. Liquid biopsy by detecting genomic material in serum is a novel diagnostic tool. A preoperative biopsy is necessary for diagnosis, prognosis and optimal planning of surgical intervention. Core needle biopsy is the most indicative and effective. Its correct performance influences surgical management. An unsuccessful biopsy means the dissemination of cancer cells into healthy anatomical structures that ultimately affect resectability and survival. Complete therapeutic excision (R0) with an acceptable resection margin of 1 cm is the method of choice. However, near significant structures, i.e., vessels, nerves, an R2 resection (macroscopic margin involvement) preserving functionality but having a risk of local recurrence can be an acceptable choice, after informing the patient, to prevent an unavoidable amputation. For borderline resectability of the tumor, neoadjuvant chemo/radiotherapy has a place. Likewise, after surgical excision, adjuvant therapy is indicated, but chemotherapy in nonmetastatic disease is still debatable. The five-year survival rate reaches up to 55%. Reresection is considered after positive or uncertain resection margins. Current strategies are based on novel chemotherapeutic agents, improved radiotherapy applications to limit local side effects and targeted biological therapy or immunotherapy, including vaccines. Young age is a risk factor for distant metastasis within 6 mo following primary tumor resection. Neoadjuvant radiotherapy lasting 5-6 wk and surgical resection are indicated for high-grade STS (grade 2 or 3). Wide surgical excision alone may be acceptable for patients older than 70 years. However, locally advanced disease requires a multidisciplinary task of decision-making for amputation or limb salvage.

Factors influencing the effectiveness of trabeculectomy: following materials of the City Multidisciplinary Hospital No. 2

BACKGROUND: Despite the ever-expanding arsenal of IOP-lowering surgeries, trabeculectomy remains the most common procedure amongst them. Therefore, the identification of factors reducing its effectiveness and potentially being able to change the surgical treatment plan is of particular importance.
 AIM: To identify factors reducing trabeculectomy effectiveness.
 MATERIALS AND METHODS: The study group consisted of 443 consecutively enrolled patients who were operated in 20162020 in Saint Petersburg City Multidisciplinary Hospital No. 2 for primary open-angle decompensated glaucoma and then observed for 6 to 24 months. Using statistical research methods, factors that significantly affected the impact of the procedure were identified.
 RESULTS: The main predictors of trabeculectomy failure following the order of decreasing importance of established relations (p) were: loss of effectiveness of the preceding IOP-lowering procedure (р = 0.0001), dry eye syndrome (р = 0.013), number of drop instillations per day (р = 0.041), and excessive preservative load due to unnecessarily aggressive topical glaucoma treatment (р = 0.039). An obvious demonstration of excessive therapy is a simultaneous administration of four IOP-lowering medications. It also causes scarring of the procedure area, especially in patients previously operated for glaucoma. Null preservative load and prostaglandin monotherapy are associated with guaranteed complete success of trabeculectomy. Unlike the intensity of medical glaucoma treatment, its duration does not have such a significant impact on trabeculectomy outcomes (р = 0.270). Close to a significant one is the relationship between poor surgical outcomes and advanced stages of the disease (р = 0.052).
 CONCLUSIONS: The main factors affecting the effectiveness of trabeculectomy were failure of the previous IOP-lowering surgeries; concomitant dry eye syndrome, arising or being aggravated by unduly intense and prolonged pharmacological effects on the eye surface; as well as delayed appliance for surgical IOP normalization at advanced disease stages.

The Influence of Cone Beam Computed Tomography-Derived 3D-Printed Models on Endodontic Microsurgical Treatment Planning and Confidence of the Operator

IntroductionCurrently, there are no studies evaluating the impact of 3-dimensional (3D) printed models on endodontic surgical treatment planning. The aims of this study were: 1) to determine if 3D models could influence treatment planning; and 2) to assess the effect of 3D supported planning on operator confidence. MaterialsEndodontic practitioners (n = 25) were asked to analyze a preselected cone beam computed tomography (CBCT) scan of an endodontic surgical case and answer a questionnaire that elucidated their surgical approach. After 30 days, the same participants were asked to analyze the same CBCT scan. Additionally, participants were asked to study and to perform a mock osteotomy on a 3D printed model. The participants responded to the same questionnaire along with a new set of questions. Responses were statistically analyzed using chi square test followed by either logistic or ordered regression analysis. Adjustment for multiple comparison analysis was done using a Bonferroni correction. Statistical significance was set at ≤0.005. ResultsThe availability of both the 3D printed model and the CBCT scan resulted in statistically significant differences in the participants' responses to their ability to detect bone landmarks, predict the location of osteotomy, and to determine the following: size of osteotomy, angle of instrumentation, involvement of critical structures in flap reflection and involvement of vital structures during curettage. In addition, the participants’ confidence in performing surgery was found to be significantly higher. ConclusionsThe availability of 3D printed models did not alter the participants’ surgical approach but it significantly improved their confidence for endodontic microsurgery.

Ileocolic neoplastic intussusception—Imaging role and surgical management: A case report

Intussusception refers to invagination of bowel loops into a neighboring, adjacent bowel segment. While it is not an uncommon entity in paediatrics-about 95% of intussusceptions occur in childhood, merely 5% of them affect the adult population. When affecting the later typically the small intestine is engaged rather than the colon. The diagnosis often represents with unspecific symptoms and is rarely considered a possibility in adults. In the past the diagnosis was typically made intraoperatively. As the Multi-Detector Computed Tomography (MDCT) of the abdomen became a referral diagnostic method, recognizing the signs of the condition is very important since some of the cases are transient, while others have an underlying malignant cause and more aggressive treatment is required. Surgical treatment planning is mandatory in those neoplastic complicated cases. The presented case report describes the role of radiology and the surgical treatment of a malignant ileocolic intussusception.

Radiographic Parameters of Adult Hip Dysplasia.

As knowledge about the origin and morphologic characteristics of hip pain in the young adult has evolved, so too has the clinician's ability to assess for various pathologies of the hip on radiographs, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA), and computed tomography (CT). Because there is no algorithm at this time directly indicating what to do in more subtle hip morphologies, such as microinstability and borderline hip dysplasia (BHD), a skilled hip preservation specialist must use multiple imaging sources and know how to interpret them correctly. Imaging parameters used in the workup for hip dysplasia and BHD include the lateral center-edge angle, Tönnis angle, iliofemoral line, and presence of an upsloping lateral sourcil or everted labrum, among many others. The purpose of this narrative review was to detail various established criteria and parameters on anteroposterior pelvis plain radiographs, MRI/MRA, and CT that assist in defining the nature and severity of instability present in a dysplastic hip, thereby aiding in the development of patient-specific surgical treatment plans.

Facial masculinization surgery

Facial masculinization surgery

Global research trends in penile cancer: Bibliometric and visualized analysis.

Penile cancer is a malignant tumor of the genitourinary system that mostly occurs in middle-aged and elderly men aged 50-70 years, which can seriously affect physical, psychological, and sexual health. Hundreds of original articles and reviews on penile cancer are published each year. However, a bibliometric analysis of these publications has not been performed. This study aimed to systematically analyze and visualize penile cancer-related publications through bibliometrics and reveal identified topics, hotspots, and knowledge gaps in related fields. Based on the Web of Science core collection database, we first analyzed the quantity and quality of publications in the field of penile cancer. Second, we profiled the publishing groups in terms of country, institution, author's publication, and cooperation network. Then, we systematized and summarized the hot topics of research. This bibliometric analysis was conducted from 2001 to 2022. The analysis identified 1,687 articles and reviews, which were published in 432 journals. The number of publications and citations on penile cancer-related research has steadily increased over the last two decades. Furthermore, academic institutions in Europe and the United States play a leading role in penile cancer research. The country, institution, journal, and author with the most publications were the United States (507), H Lee Moffitt Cancer Research Center (96), Journal of Urology (83), and Spiess P (87), respectively. The most frequently used keywords were penile cancer (743), squamous-cell carcinoma (717), cancer (380), carcinoma (232), lymphadenectomy (229). 16 keyword clustering information was obtained, including #0 male circumcision, #1 lichen sclerosus, #2 chemotherapy, #3 penile neoplasms, #4 targeted therapy, #5 resection margin, #6 cervical cancer, #7 lymph node dissection, #8 prognostic factor, #9 prostate cancer, #10 inguinal lymph node dissection, #11 human papillomavirus DNA, #12 gene, #13 penile intraepithelial neoplasia, #14 male sexual function, and #15 penile cancer. More and more scholars are devoted to the research on penile cancer. This bibliometric analysis revealed that the main research topics and hotspots in penile cancer included risk factors and surgical treatment plans.

Deep-learning method for fully automatic segmentation of the abdominal aortic aneurysm from computed tomography imaging.

Abdominal aortic aneurysm (AAA) is one of the leading causes of death worldwide. AAAs often remain asymptomatic until they are either close to rupturing or they cause pressure to the spine and/or other organs. Fast progression has been linked to future clinical outcomes. Therefore, a reliable and efficient system to quantify geometric properties and growth will enable better clinical prognoses for aneurysms. Different imaging systems can be used to locate and characterize an aneurysm; computed tomography (CT) is the modality of choice in many clinical centers to monitor later stages of the disease and plan surgical treatment. The lack of accurate and automated techniques to segment the outer wall and lumen of the aneurysm results in either simplified measurements that focus on few salient features or time-consuming segmentation affected by high inter- and intra-operator variability. To overcome these limitations, we propose a model for segmenting AAA tissues automatically by using a trained deep learning-based approach. The model is composed of three different steps starting with the extraction of the aorta and iliac arteries followed by the detection of the lumen and other AAA tissues. The results of the automated segmentation demonstrate very good agreement when compared to manual segmentation performed by an expert.

Management of Dermoid Cysts in Pregnancy at a Tertiary Care Centre: A Retrospective Observational Study

Introduction: Ovarian masses are not uncommon in pregnancy. The increased use of Ultrasonography (USG) in recent years has led to the detection of asymptomatic ovarian masses in pregnant women. Dermoid cysts are the most common type of ovarian germ cell tumour in pregnancy. Most of them are asymptomatic and are incidental findings. However, a few can present with complications such as torsion and rupture. The diagnosis and management of dermoid cysts in pregnancy present a clinical dilemma. Aim: To evaluate the management and outcomes of antenatal patients diagnosed with dermoid cysts. Materials and Methods: A retrospective observational study was conducted in the Department of Obstetrics and Gynaecology at Christian Medical College, Vellore, Tamil Nadu, India, from January 2015 to January 2022. The study included 37 patients, and data regarding the diagnosis of dermoid cysts, their radiological and clinical characteristics, management, and pregnancy outcomes were collected from the electronic database. Descriptive statistics were used for reporting demographic and clinical characteristics. Categorical variables were presented as numbers with percentages, while continuous variables were presented as mean with Standard Deviation (SD) or median with Interquartile Range (IQR). Results: The dermoid cysts ranged in size from 2.2 cm to 30 cm, with a mean size of 7.28±4.51 cm. A total of 35 (95%) of them were incidentally detected. USG was the imaging modality used for diagnosis and follow-up. Only 30% (11/37) of the patients required surgical intervention during the antenatal period. Torsion was the indication for emergency surgical intervention in 46% (5/11) of cases. Laparoscopy was the preferred approach for surgical intervention in 91% (10/11) of patients. The remaining 70% (26/37) of patients were managed conservatively with serial USG, and no adverse outcomes were reported. Among the patients who underwent caesarean section for obstetric indications, 35% (13/37) also underwent surgical intervention for the dermoid cyst (either cystectomy or oophorectomy) during the same procedure. Conclusion: Antenatal patients diagnosed with dermoid cysts during pregnancy can be managed conservatively with serial USG, with a plan for surgical intervention if needed. In cases where surgical intervention is required, it can be safely performed as a laparoscopic procedure. In case of complications such as torsion, laparoscopy can be performed during pregnancy with appropriate precautionary measures.

Компьютерная томография и ультразвуковое исследование в диагностики некротизирующего фасциита

The purpose — to demonstrate the capabilities of computed tomography and ultrasound in the diagnosis and treatment planning of a patient with a rare case of necrotizing fasciitis. Material and methods. A clinical observation of a 57-year-old patient K. with complaints of pain in the area of the right foot, reddening of the skin on the right foot is presented. T — 37.2 ºC. To determine the nature of the revealed changes, the patient was referred to the Department of Radiation and Functional Diagnostic Methods for soft tissue ultrasound and computed tomography (CT) of the vessels of the lower extremities to assess the lesion and plan surgical treatment. Results. After an ultrasound of the soft tissues of the right leg posterior surface, around the gastrocnemius muscle, an inhomogeneous liquid rim (an echo picture of fasciitis), soft tissue edema was visualized. CT of the lower extremities vessels showed a decrease in blood flow in the lower leg arteries, infiltration and a moderate amount of gas in the soft tissues of n/3 of the lower leg and foot. Discussion. Necrotizing fasciitis (fasciitis necrotisans) is a representative of a large group of surgical infections of soft tissues, the morphological basis of which is progressive necrosis of the superficial fascia (fascia superficialis) and subcutaneous adipose tissue, and the clinical course is particularly severe and is accompanied by high mortality. NF is an emergency surgical situation. Early and accurate diagnosis is critical to provide the necessary aggressive treatment. Conclusion. This clinical observation demonstrates the importance of conducting a study using computed tomography and ultrasound in patients with necrotizing fasciitis for the earliest possible diagnosis and immediate surgical treatment, supported by effective antibiotic therapy.

Radiation Oncology-Future Vision for the Modern Radiation Oncologist

Radiation oncology has evolved as a discipline and the physicians who practice radiation oncology are adapting to the changing landscape of oncology management. The skill set for the modern radiation oncologist has matured as the requirements for modern patient care have become increasingly complex both in patient evaluation and treatment execution. Radiation oncology interacts with all medical and surgical subspecialties and advanced radiation therapy treatment plans require nimble use of volumetric anatomic and metabolic image sets and applied pathology to contour targets for successful treatment. Although multidisciplinary care management can serve to confirm and validate a treatment plan among providers, the number of providers involved with an individual patient management plan can also generate confusion and mixed messaging for the patient and their family. Because radiation oncologists work with every discipline and see patients weekly on treatment, often the relationship between the radiation oncologist and the patient can serve as a bridge between disciplines and radiation oncologists can serve to align the disciplines with the patient to re-affirm the care plan, limit confusion, and generate confidence for the patient with the plan and the providers. In this chapter, we will review the changing role of the radiation oncologist as we continually move directly into the mainstream of patient care, in equal partnership to medical oncology with highly advanced tools for modern therapy. Survivorships models of care will mature as radiation oncologists become more integrated into primary and follow up management of each cancer patient.

Comparison of the Effectiveness of Ultrasound Imaging and Perioperative Measurement in the Diagnosis and Characterization of Incisional Hernia.

Incisional hernia (IH) is a common complication after abdominal surgery, and there is no gold standard imaging modality for its diagnosis. Although computed tomography is frequently used in clinical practice, it has limitations such as radiation exposure and relatively high cost. The aim of this study is to establish standardization and hernia typing by comparing preoperative ultrasound (US) measurements and perioperative measurements in IH cases. The patients who were operated for IH in our institution between January 2020 and March 2021 were reviewed, retrospectively. In result, 120 patients were included in the study, and the cases had preoperative US images and perioperative hernia measurements. IH was divided into three subtypes as omentum (Type I), intestinal (Type II), and mixed (Type III) according to the defect content. Type I IH was detected in 91 cases, Type II IH in 14 cases, and Type III IH in 15 cases. When the diameters of IH types were compared for preoperative US and perioperative measurements, respectively, there was no statistical significance (P = 0.185 and P = 0.262). According to Spearman correlation, there was a positive very strong correlation between preoperative US measurements and perioperative measurements (ρ = 0.861 and P < 0.001). As stated by our results, US imaging can be performed easily and quickly, providing a reliable way to accurately detect and characterize an IH. It can also facilitate the planning of surgical intervention in IH by providing anatomical information.

Evaluation of jaw bone changes in patients with asthma using inhaled corticosteroids with mandibular radiomorphometric indices on dental panoramic radiographs.

Inhaled corticosteroids (ICSs) are an effective drug commonly used in asthma treatment. It is known that osteoporotic changes can occur secondary to steroid usage, depending on dosage and duration. The aim of this study was to compare radiomorphometric indices and fractal dimension on panoramic images of patients with asthma using ICSs and healthy controls. A total of 66 dental panoramic radiographs (DPRs) taken from 32 patients with asthma using ICSs and 34 healthy individuals were evaluated in this retrospective study. Panoramic mandibular index inferior and superior (PMI-i,PMI-s), mandibular cortical width (MCW), gonial index (GI), antegonial index (AI), mandibular cortical index (MCI), and fractal dimension analysis (FDA) were measured on DPRs. PMI-s (p=0.02), MCW (p<0.001), GI (p<0.001) and AI (p<0.001) values were significantly lower in the group of the asthma using ICSs than control group. However, the PMI-i (p ˃0.05) measurement, the MCI (p ˃0.05) and FDA values distribution were similar in both groups. The use of ICSs in asthma patients can affect bone quality. The evaluation of PMI-s, MCW, GI, and AI on DPR can help determine the effect of this drug on the jawbones in the early period and select dental and surgical treatment plans appropriately.

Use of TWIST Score and BAL Score in Diagnosing Testicular Torsion in Children with Acute Scrotum: A Retrospective Study

Introduction: Early diagnosis and management of Torsion Testis (TT) in children is challenging. To improve the reliability of diagnosis, various clinical scoring systems have been proposed. Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score and Boettcher Alert (BAL) score have been used for the diagnosis of TT in children with acute scrotum. Aim: To find the utility of TWIST and BAL score for diagnosing testicular torsion in children with acute scrotum. Materials and Methods: This was a retrospective recordbased study that included medical records of children with acute scrotum who underwent surgery between January 2019 and December 2021 in a tertiary care hospital. A total of 112 patients were included in the study. TWIST and BAL scores were calculated, retrospectively. Univariate analysis of the clinical features were done using Chi-square test. Sensitivity, specificity, Positive Predicitive Value (PPV) and Negative Predicitive Value (NPV) for scoring systems were calculated. Results: There were 73 patients in TT group and 39 in Non Torsion Testis (NTT) group. The mean age was 4.5±2.98 years in torsion group and 5.2±2.2 years in non torsion group. Among the components of TWIST and BAL score, absent cremasteric reflex, hard testicle, high riding testis, nausea/vomiting and pain duration &lt;24 hours were found to be statistically significant. PPV and specificity of TWIST score ≥5 were 98.15% and 97.44%, respectively whereas NPV and sensitivity of BAL score ≥2 group was 100%. Conclusion: TWIST and BAL scores are reliable bedside and easy to perform clinical diagnostic tools for TT. These scores can help in early detection and plan surgical intervention to reduce ischaemia time of TT.

Spinal Metastases and the Evolving Role of Molecular Targeted Therapy, Chemotherapy, and Immunotherapy.

Metastatic involvement of the spine is a common complication of systemic cancer progression. Surgery and external beam radiotherapy are palliative treatment modalities aiming to preserve neurological function, control pain and maintain functional status. More recently, with development of image guidance and stereotactic delivery of high doses of conformal radiation, local tumor control has improved; however recurrent or radiation refractory disease remains a significant clinical problem with limited treatment options. This manuscript represents a narrative overview of novel targeted molecular therapies, chemotherapies, and immunotherapy treatments for patients with breast, lung, melanoma, renal cell, prostate, and thyroid cancers, which resulted in improved responses compared to standard chemotherapy. We present clinical examples of excellent responses in spinal metastatic disease which have not been specifically documented in the literature, as most clinical trials evaluate treatment response based on visceral disease. This review is useful for the spine surgeons treating patients with metastatic disease as knowledge of these responses could help with timing and planning of surgical interventions, as well as promote multidisciplinary discussions, allowing development of an individualized treatment strategy to patients presenting with widespread multifocal progressive disease, where surgery could lead to suboptimal results.

3D modeling and printing for complex biventricular repair of double outlet right ventricle.

Double outlet right ventricle (DORV) describes a group of congenital heart defects where pulmonary artery and aorta originate completely or predominantly from the right ventricle. The individual anatomy of DORV patients varies widely with multiple subtypes classified. Although the majority of morphologies is suitable for biventricular repair (BVR), complex DORV anatomy can render univentricular palliation (UVP) the only option. Thus, patient-specific decision-making is critical for optimal surgical treatment planning. The evolution of image processing and rapid prototyping techniques facilitate the generation of detailed virtual and physical 3D models of the patient-specific anatomy which can support this important decision process within the Heart Team. The individual cardiovascular anatomy of nine patients with complex DORV, in whom surgical decision-making was not straightforward, was reconstructed from either computed tomography or magnetic resonance imaging data. 3D reconstructions were used to characterize the morphologic details of DORV, such as size and location of the ventricular septal defect (VSD), atrioventricular valve size, ventricular volumes, relationship between the great arteries and their spatial relation to the VSD, outflow tract obstructions, coronary artery anatomy, etc. Additionally, physical models were generated. Virtual and physical models were used in the preoperative assessment to determine surgical treatment strategy, either BVR vs. UVP. Median age at operation was 13.2 months (IQR: 9.6-24.0). The DORV transposition subtype was present in six patients, three patients had a DORV-ventricular septal defect subtype. Patient-specific reconstruction was feasible for all patients despite heterogeneous image quality. Complex BVR was feasible in 5/9 patients (55%). Reasons for unsuitability for BVR were AV valve chordae interfering with potential intraventricular baffle creation, ventricular hypoplasia and non-committed VSD morphology. Evaluation in particular of qualitative data from 3D models was considered to support comprehension of complex anatomy. Image-based 3D reconstruction of patient-specific intracardiac anatomy provides valuable additional information supporting decision-making processes and surgical planning in complex cardiac malformations. Further prospective studies are required to fully appreciate the benefits of 3D technology.

PSAT214 Management of Hyperparathyroidism Associated with Severe Hypercalcemia Presenting During Labour

Abstract Background Hypercalcemia is a rare pathology in pregnancy, and primary hyperparathyroidism (PHPT) has been described as the most common cause. No guidelines exist concerning treatment of PHPT during pregnancy, although most authors favor surgery as the treatment of choice during the second trimester. Nonetheless, management during the third trimester of pregnancy is challenging due to lack of current guidelines. Clinical case This 29-year pregnant female presenting at 38-weeks gestation with spontaneous rupture of membranes and admitted for latent labor. She was incidentally found to have hypercalcemia. Endocrinology was consulted for asymptomatic hypercalcemia in the third trimester of pregnancy. A diagnosis of primary hyperparathyroidism (PHPT) was suspected based on elevated serum calcium adjusted for albumin (16 mg/dL, normal range 8.5-10.5 mg/dL) and elevated PTH levels (121 pg/mL, normal range 14-65 pg/mL). In addition, parathyroid hormone related peptide (PTHrP) was less than 2.0 pmol/L (normal range &amp;lt;2.0 pmol/L), 25-hydroxy vitamin D was 35.6 ng/mL (normal range 30-50 ng/mL) and urine calcium/creatinine clearance ratio (CCCR) level was 0.02 (&amp;lt;0.01 familial hypocalciuric hypercalcemia is likely, &amp;gt;0.02 PHPT is likely) further supporting the diagnosis of PHPT. No parathyroid imaging was performed as there was no plan for surgical intervention at that time. Conservative management was initiated with aggressive oral and intravenous fluid rehydration. The patient subsequently had an uneventful vaginal delivery with the arrival of a healthy newborn eight hours after treatment was initiated. With continued IV and oral hydration, corrected calcium fell by a total of 5 mg/dL. Given an uneventful postpartum course as well as improving calcium levels with hydration, the patient was discharged on day three of hospitalization with a plan for outpatient endocrinology follow up in preparation for future parathyroidectomy. Conclusion There is no previous case report describing severe hypercalcemia in the third trimester of pregnancy managed conservatively solely with hydration. Calcitonin has been attempted but use is limited secondary to tachyphylaxis. Additionally, some case reports suggest cinacalcet use but this drug crosses the placenta. In this unique and complicated case of severe hypercalcemia diagnosed in the third trimester of pregnancy, conservative management with intensive oral and intravenous fluid rehydration was safe and effective in lowering serum calcium levels and therefore conducive to a positive pregnancy outcome. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Bimaxillary Distalization with Skeletal Anchorage for Management of Severe Skeletal Class III Open Bite Malocclusion.

Adult patients with severe vertical growth pattern, skeletal class III malocclusion and open bite anteriorly are difficult orthodontic cases to treat. An orthognathic surgical treatment plan may benefit adult patients with such types of complex malocclusions, however in certain cases, the patient's medical history may contraindicate the surgical treatment plan. A male patient aged 17 years presented with a prognathic mandible, Angle's class III malocclusion on a class III skeletal base with proclination in upper incisors, retroclination of lower incisors, and reduced facial convexity. Patient gave history of asthma and complex cardiac diseases including arrhythmia, irregular heartbeat, and pacemaker. This case report describes a non-surgical approach of distalization of mandibular and maxillary arches performed with the help of miniplates to achieve an improvement in the facial balance without surgery.