Preoperative Clinical Evaluation Research Articles

Last minute cancellation of elective lung cancer surgery is associated with poorer survival.

Our objective was to assess the incidence and reason of last-minute cancellations before surgery for lung cancer and their association with outcomes. Retrospective analysis on all consecutive patients booked for elective lung cancer surgery from January 2017 through December 2022 in a single centre.Last minute cancellation: a cancellation occurring within the last 24 hours from the planned operation. Cancellation categories: process-related and patient-related.The short-term and long-term outcomes of patients who experienced a last-minute cancellation were analysed. 197 patients of 1587 (12%) had a last-minute cancellation: 156 (79%) were process-related and 41 (21%) were patient-related.3% (5/156) of patients cancelled for process reasons did not receive surgery vs 39% (16/41) of those cancelled for patient-related reasons, p < 0.0001.The 90-day mortality rates of cancelled and non-cancelled patients were similar (4.6% vs 4.7%, p = 1).Five-year overall survival of patients with cancellation was 58% (95% CI 49-66) vs 69% (95% CI 66-71) of those without cancellations, p = 0.022.Among those who had a cancellation, the 5-year OS of those with process-related cancellations was 61% (52-60) vs 35% (14-58) of those with patient-related cancellations (adjusted p value for multiple comparisons = 0.14).Cox regression analysis showed that surgery cancellations within the last 24 hours for patient-related (HR 1.87, 95% CI 1.02-3.42, p = 0.043) reasons remained a factor associated with poorer overall survival after adjusting for clinical stage, type of operation and patient related variables. Implementing the patient's preoperative clinical evaluation to reduce the occurrence of related last-minute cancellations might mitigate its negative impact on survival.

The use of ultrasound to predict flexor tendinopathy after anterior locking plating of the distal radius.

This study compares ultrasound to clinical and radiographic measurements for assessing tendon pathology associated with distal radial anterior locking plates. A total of 46 patients undergoing removal of a distal radial plate had a preoperative clinical examination, radiographs and ultrasound evaluation to detect evidence of tendon irritation. Gross changes to the tendon were assessed during plate removal. In total, 32 patients demonstrated clinical abnormality. Soong 2 position was noted in 13 patients. Ultrasound revealed tenosynovitis in nine patients, tendon fibrillation or thickening in four patients and a single case of partial discontinuity. Intraoperative assessment revealed tenosynovitis in 28 patients and tendon fibre discontinuity in eight patients. Ultrasound findings were not predictive of intraoperative tenosynovitis and discontinuity. A relationship was noted between higher Soong grade, especially grade 2, and intraoperative presence of tenosynovitis, as well as Soong grade and amount of soft-tissue coverage. This study negates our hypothesis that ultrasound is useful for identifying tendinopathy after distal radial anterior plate fixation.Level of evidence: II.

The Use of Pressure Recording Analytical Method in Patients Undergoing Endovascular Repair for Abdominal Aortic Aneurysm: The Impact on Clinical Decisions for the Appropriate Postoperative Setting and Cost-effective Analysis.

To analyze the use of the Pressure Recording Analytical Method (PRAM), an hemodynamic monitoring system, in evaluating intraoperative and postoperative hemodynamic instability in patients undergoing endovascular repair for abdominal aortic aneurysm, and to evaluate if the decision to refer patients to a ordinary ward or to a Cardiac Step-Down Unit (CSDU) after the intervention on the basis of intraoperative hemodynamic monitoring could be more cost-effective. After preoperative clinical evaluation, 44 patients were divided in this non-randomised study into two groups according to their postoperative destination: Group 1-ward (N=22) and Group 2-CSDU (N=22). All patients underwent monitoring with PRAM during the intervention and in the 24 postoperative hours, measuring several indices of myocardial contractility and other hemodynamic variables. According to the variability of two parameters, Stroke Volume Variation and Pulse Pressure Variation, patients were classified as stable or unstable. Unstable patients showed a significant alteration in several hemodynamic indices, in comparison to stable ones. According to the intraoperative monitoring, eight high risk patients could have been sent to an ordinary ward due to their stability, with a reduction in the improper use of CSDU and, consequently, in costs. Hemodynamic monitoring with PRAM can be useful in these patients, both for intraoperative management and for the choice of the more appropriate postoperative setting, possibly reducing the improper use of CSDU for hemodynamically stable patients who are judged to be at high risk preoperatively, and re-evaluating low surgical risk patients with an unstable intraoperative pattern, with a possible reduction in costs.

Predictive value of preoperative CT enhancement rate and CT perfusion parameters in colorectal cancer

BackgroundAngiogenesis is a critical step in colorectal cancer growth, progression and metastasization. CT are routine imaging examinations for preoperative clinical evaluation in colorectal cancer patients. This study aimed to investigate the predictive value of preoperative CT enhancement rate (CER) and CT perfusion parameters on angiogenesis in colorectal cancer, as well as the association of preoperative CER and CT perfusion parameters with serum markers.MethodsThis retrospective analysis included 42 patients with colorectal adenocarcinoma. Median of microvessel density (MVD) as the cut-off value, it divided 42 patients into high-density group (MVD ≥ 35/field, n = 24) and low-density group (MVD < 35/field, n = 18), and 25 patients with benign colorectal lesions were collected as the control group. Statistical analysis of CER, CT perfusion parameters, serum markers were performed in all groups. Receiver operating curves (ROC) were plotted to evaluate the diagnostic efficacy of relevant CT perfusion parameters for tumor angiogenesis; Pearson correlation analysis explored potential association between CER, CT perfusion parameters and serum markers.ResultsCER, blood volume (BV), blood flow (BF), permeability surface (PS) and carbohydrate antigen 19 − 9 (CA19-9), carbohydrate antigen 125 (CA125), carcinoembryonic antigen (CEA), trefoil factor 3 (TFF3), vascular endothelial growth factor (VEGF) in colorectal adenocarcinoma were significantly higher than those in the control group, the parameters in high-density group were significantly higher than those in the low-density group (P < 0.05); however, the time to peak (TTP) of patients in colorectal adenocarcinoma were significantly lower than those in the control group, and the high-density group showed a significantly lower level compared to the low-density group (P < 0.05). The combined parameters BF + TTP + PS and BV + BF + TTP + PS demonstrated the highest area under the curve (AUC), both at 0.991. Pearson correlation analysis showed that the serum levels of CA19-9, CA125, CEA, TFF3, and VEGF in patients showed positive correlations with CER, BV, BF, and PS (P < 0.05), while these indicators exhibited negative correlations with TTP (P < 0.05).ConclusionsSome single and joint preoperative CT perfusion parameters can accurately predict tumor angiogenesis in colorectal adenocarcinoma. Preoperative CER and CT perfusion parameters have certain association with serum markers.

The model for predicting the central lymph node metastasis in cN0 papillary thyroid microcarcinoma with Hashimoto's thyroiditis.

The relationship between Hashimoto's thyroiditis (HT) and papillary thyroid microcarcinoma (PTMC) is controversial. These include central lymph node metastasis (CLNM), which affects the prognosis of PTMC patients. This study aimed to establish a predictive model combining ultrasonography and clinicopathological features to accurately evaluate latent CLNM in PTMC patients with HT at the clinical lymph node-negative (cN0) stage. In this study, 1102 PTMC patients who received thyroidectomy and central cervical lymph node dissection (CLND) from the First Affiliated Hospital of Shandong First Medical University from January 2021 to December 2022 and the 960th Hospital of PLA from January 2021 to December 2022 were jointly collected. The clinical differences between PTMCs with HT and those without HT were compared. A total of 373 PTMCs with HT in cN0 were randomly divided into a training cohort and a validation cohort. By analyzing and screening the risk factors of CLNM, a nomogram model was established and verified. The predictive performance was measured by the receiver operating characteristic (ROC) curve, calibration curve, and clinical decision curve analysis (DCA). The ratio of central lymph node metastasis (CLNMR) in PTMCs with HT was 0.0% (0.0%, 15.0%) and 7.7% (0.0%, 40.0%) in the non-HT group (P<0.001). Multivariate logistic regression analysis showed that age, gender, calcification, adjacent to trachea or capsule, and TPOAB were predictors of CLNM in PTMCs with HT. The areas under the curve (AUC) of the prediction models in the training cohort and the validation cohort were 0.835 and 0.825, respectively, which showed good differentiation ability. DCA indicates that the prediction model also has high net benefit and clinical practical value. This study found that CLN involvement was significantly reduced in PTMC patients with HT, suggesting that different methods should be used to predict CLNM in PTMC patients with HT and without HT, to more accurately assist preoperative clinical evaluation. The actual CLNM situation of PTMCs with HT in cN0 can be accurately predicted by the combination of ultrasonography and clinicopathological features.

Changes in lower urinary tract function after minimally invasive nerve-sparing for complete excision of endometriosis: An observational study.

The objective of this paper is to evaluate changes in lower urinary tract symptoms (LUTS), severity of pain and urodynamic parameters after minimally invasive nerve-sparing surgery for patients with endometriosis. We analyzed 143 patients undergoing minimally invasive nerve-sparing surgery for endometriosis excision (laparoscopy/robot-assisted). The endometriosis was confirmed by preoperative clinical evaluation, magnetic resonance imaging (MRI) showing at least one lesion deeper than 5 mm, and histological confirmation after laparoscopy. We evaluated three points prior and after surgery: LUTS parameters according to the International Urogynecological Association; urodynamic measures of storage and voiding and the severity of the dyspareunia, dyschezia and dysmenorrhea assessed on a self-reported 11-point numeric rating scale. The Wilcoxon signed rank and McNemar tests were used for statistical analyses (p < 0.05). We observed significant improvements in LUTS after the surgery with postoperative symptom-free probabilities in urgency (64.5%), daytime frequency (38.5%), and dysuria (87.1%). However, slow stream prevalence increased significantly postsurgery (p = 0.022), with a 20.5% risk of asymptomatic patients developing this symptom. Urodynamic responses varied; for instance, maximum cystometric capacity improved significantly (p = 0.004), while postvoiding residual worsened (p = 0.006). Significant worsening in postvoiding residual occurred in women with normal preoperative values (p = 0.002), with a 17.7% risk of normal values becoming abnormal. Compliance or maximum cystometric capacity not considered normal preoperatively showed significant improvements (p < 0.001), but the risk of normal values becoming abnormal after surgery was 14.5%. The minimally invasive nerve-sparing surgery for endometriosis excision shows improvement in lower urinary tract symptoms, urodynamics parameters and severity of pain. The majority of patients became asymptomatic in the postoperative period. When compared to the benefits of the patients' surgical treatment, particularly when considering the reduction of pain, the risks of the lower urinary tract treatment seem to be acceptable. The surgical intervention seems to be a safe alternative in patients with endometriosis, although studies with larger samples are needed to confirm these findings.

An Ultrasound-Based Preoperative Evaluation of the Endometriosis Fertility Index: A Further Step towards Personalized Treatment.

Background: The Endometriosis Fertility Index (EFI), is a crucial validated surgical tool used for predicting fertility outcomes in women with endometriosis. This study aims to assess the concordance between a preoperative clinical and instrumental EFI evaluation (uEFI) and the EFI score obtained during an exploratory laparoscopy prior to surgery (sEFI). Methods: This study presents preliminary data from a broader observational cohort study. The Least Function score for the uEFI was calculated using a modified version of the original surgical EFI by incorporating a clinical examination, advanced ultrasound, and hysterosalpingo-foam sonography (HyFoSy). Results: The preoperative estimation of the EFI (uEFI) demonstrated a high concordance (k = 0.695, ρs = 0.811) with the sEFI. Remarkably, the surgical interventions led to a significant improvement in the EFI values, with 80% of the intermediate EFI transitioning to a high level, thereby highlighting the positive impact of surgery on fertility outcomes. Conclusion: This study highlights the accuracy of preoperative EFI estimation (uEFI) and its strong agreement with intraoperative assessment. It underscores the potential of a preoperative management tool to guide the allocation of infertile women with endometriosis to operative laparoscopy, direct assisted reproductive technology (ART), or spontaneous attempts at pregnancy.

Preoperative anaesthesia assessment and patient preparation for surgery: update and a review

Although anaesthetic and surgical procedures should be individualised for every patient, in practice many preoperative protocols and routines are used generally. The “Helsinki Declaration on Patient Safety in Anaesthesiology” establishes that the safety and quality of the perioperative care received by patients is the responsibility of anaesthesiologists. This declaration has been accepted by all the European Societies of Anaesthesiology and stipulates that all institutions providing perioperative anaesthesia care to patients should design protocols to guide perioperative patient management. The present article aims to provide an evidenced-based review of preoperative assessment and preparation and to propose a protocol that can be adapted to the needs of each hospital and be incorporated into their routine practice. Emphasis is placed on the importance of correct preoperative evaluation in reducing morbidity and mortality in the surgical patient. This task can be aided by the use of preoperative questionnaires and the rational use of preoperative tests, which will also reduce unnecessary costs. Finally, the most widely accepted recommendations on preoperative fasting is discussed. The anaesthesiologist’s legal responsibility, and patients’ views in the preoperative process are also considered. A thorough clinical preoperative evaluation of the patient is more important than routine preoperative tests, which should be requested only when justified by clinical indications. Moreover, this practice eliminates unnecessary cost without compromising the safety and quality of care.

Imaging in Third Molar Surgery: A Clinical Update.

Third molar surgery is one of the most common surgical procedures performed in oral and maxillofacial surgery. Considering the patient's young age and the often-elective nature of the procedure, a comprehensive preoperative evaluation of the surgical site, relying heavily on preoperative imaging, is key to providing accurate diagnostic work-up, evidence-based clinical decision making, and, when appropriate, indication-specific surgical planning. Given the rapid developments of dental imaging in the field, the aim of this article is to provide a comprehensive, up-to-date clinical overview of various imaging techniques related to perioperative imaging in third molar surgery, ranging from panoramic radiography to emerging technologies, such as photon-counting computed tomography and magnetic resonance imaging. Each modality's advantages, limitations, and recent improvements are evaluated, highlighting their role in treatment planning, complication prevention, and postoperative follow-ups. The integration of recent technological advances, including artificial intelligence and machine learning in biomedical imaging, coupled with a thorough preoperative clinical evaluation, marks another step towards personalized dentistry in high-risk third molar surgery. This approach enables minimally invasive surgical approaches while reducing inefficiencies and risks by incorporating additional imaging modality- and patient-specific parameters, potentially facilitating and improving patient management.

MRI Criteria for Healing at 1 Year After Repair of a Traumatic Meniscal Tear

Background: Meniscal repair for a traumatic meniscal tear is increasingly used to preserve the meniscus. Interpreting postoperative magnetic resonance imaging (MRI) scans remains challenging, especially in symptomatic patients. There is a lack of reliable MRI criteria to affirm the healed character of a traumatic meniscal injury repair. Purpose: To identify relevant MRI criteria for meniscal healing after meniscal repair. Study Design: Case series; Level of evidence, 4. Methods: We prospectively included all patients with a traumatic meniscal injury who underwent either an isolated meniscal repair or a repair during a concomitant anterior cruciate ligament reconstruction. A standardized preoperative and postoperative clinical evaluation was performed, along with collection of functional scores—Knee injury and Osteoarthritis Outcome Score, International Knee Documentation Committee, Lysholm Score, and 36-Item Short Form Health Survey. An MRI scan was performed 1 year postoperatively and compared with the preoperative MRI scan. The following MRI aspects were analyzed: variation of morphology and fat-saturated (FS) T2 intensity signal and pre- and postoperative tear diastasis measurement. Results: Fifty patients (age, mean ± SD, 28.7 ± 8.5 years [range, 16-45 years]) who were 1 year postoperative were included. All patients were considered clinically healed had the same MRI characteristics. A signal change (FS T2) was observed from a high signal intensity fluid to a nonfluid moderate signal intensity. The morphology of the lesion was more complex: from the initial lesion, line ramifications appeared, creating the appearance of tree branches. The tear diastasis decreased (from 2.3 ± 0.5 mm [range, 1.3-3.5] to 1.1 ± 0.28 mm [range, 0.5-1.5]). Conclusion: MRI criteria confirming meniscal healing after traumatic meniscal repair at 1 year were identified: a change in the intrameniscal signal becoming nonfluid and moderate in intensity; a reduction in tear diastasis to <1.5 mm; and a change in the signal morphology of the repaired meniscus.

The Outcome of Scaphoid Fracture Nonunion Managed by 1,2 Intercompartmental Supraretinacular Artery (1,2 ICSRA) Vascularized Bone Graft.

Scaphoid fracture is most often missed and mismanaged leading to scaphoid nonunion with or without avascular necrosis. When avascular necrosis of the proximal pole is confirmed with intraoperative evaluation, conventional bone graft is not enough. The treatment modalities are evolving day by day. The current trend is vascular bone grafting, which has shown good outcomes in terms of union and wrist function. Fifty patients with nonunion fracture of the scaphoid were treated with vascularized pedicle bone graft from the dorsum of the distal radius using the 1st and 2nd intercompartmental supraretinacular artery, from 2014 to 2022. Preoperative and postoperative clinical evaluation included pain, range of motion, grip strength, and satisfaction. The average follow-up period was 12 months. Among 18 patients, 14 were clinically improved after a mean follow-up period of eight weeks. Thirteen patients reported the absence of any discomfort, three patients reported slight discomfort after hard work, and two patients reported pain with light work. The wrist range of motion improved significantly, and the hand grip strength also improved. According to the modified Mayo wrist scoring chart, clinical results were rated as excellent in 24 cases, good in 19 cases, and poor in four cases. 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

Clinical and Radiological Outcomes of Computer-Assisted versus Conventional Total Knee Arthroplasty at 5-Year Follow-Up: Is There Any Benefit?

Computer-assisted total knee arthroplasty (CAS) remains controversial. Some authors defend that its improvement in knee alignment and positioning positively impacts arthroplasty survival rates, while others have stated that there is minimal or no difference compared to the conventional technique (cTKA). This paper features a retrospective, single-center, single-surgeon study, evaluating CAS surgery vs. regular cTKA in patients who consecutively underwent surgery between 2015 and 2017 (60 CAS patients vs. 59 cTKA). Data collection includes surgery duration, length of stay, blood loss and both preoperative and postoperative clinical outcome evaluation using WOMAC, SF-12, Forgotten Joint Score and VAS. Radiograph evaluation includes the tibiofemoral angle, posterior condylar offset and its ratio, and notching frequency and measurement. A total of 119 patients were included: 60 in the CAS group and 59 in the cTKA. Mean follow-up was 5.61 years (Max 7.83-Min 5.02 years). No clinically relevant preoperative differences were observed between the groups. Postoperatively, both groups showed similar functional results (WOMAC, SF-12, FJS, KSS, and VAS) with similar complication rates. The CAS group had an increased surgery time by a mean of 12 min (107.02 ± 15.22 vs. 95.32 + 13.87; p = 0.00) as well as a higher notching frequency and size (40% vs. 13.60%; p = 0.013; 1.239 mm ± 1.7604 vs. 0.501 mm ± 1.4179; p = 0.031). CAS obtained similar functional, radiological, and complication rates to cTKA at the expense of increasing surgery time and notching frequency and size.

Preoperative low handgrip strength (HGS) with HGS asymmetry is associated with adverse outcomes among older adults with gastric cancer

IntroductionThis study aimed to explore the associations of low hand grip strength (HGS), HGS asymmetry, their combinations, and frailty on hospital readmissions, total complications, and prolonged length of stay (PLOS) among older adults with gastric cancer. Materials and MethodsThis study included 342 patients with gastric cancer aged ≥60 years who were scheduled to undergo radical surgery. The Tilburg Frailty Indicator (TFI) was used to collect information on frailty. HGS was measured twice for each hand using an electronic handgrip dynamometer. The highest HGS readings on each hand were used for calculating the HGS asymmetry ratio: non-dominant HGS (kg)/dominant HGS (kg). The Fine and Gray proportional subdistribution hazard model and the logistic regression model were used for the analyses, with covariates adjusted. ResultsLow HGS (subdistribution hazard ratios [SHR] = 2.10, 95% confidence interval [CI] = 1.05–3.93, P = 0.036) and low HGS with HGS asymmetry (SHR = 3.95, 95% CI = 1.50–10.36, P = 0.005) were significantly associated with hospital readmissions. Frailty was associated with total complications (odds ratio [OR] = 2.87, 95% CI = 1.61–5.13, P < 0.001) and PLOS (OR = 1.98, 95% CI = 1.19–3.29, P < 0.001). Low HGS, HGS asymmetry, and their combinations were not significantly associated with total complications and PLOS. DiscussionPreoperative low HGS and low HGS with HGS asymmetry were associated with hospital readmissions, while frailty was associated with total complications and PLOS among older adults with gastric cancer. In the future, more rigorously designed studies are needed to verify our results further to improve preoperative clinical assessment and frailty evaluation among older adults with gastric cancer.

Application of an ultrasound-guided bilateral erector spinae plane block after the Nuss procedure for pectus excavatum in children: a retrospective cohort study with propensity score matching.

To retrospectively analyze the effect of applying an ultrasound-guided bilateral erector spine plane block (ESPB) after the Nuss procedure for surgical repair of pectus excavatum (PE) in children. The subjects of the study were patients with severe PE who received the Nuss procedure in our hospital between 1 January 2019 and 30 November 2021. According to different methods for postoperative pain management, the enrolled patients were divided into two groups, the ultrasound-guided ESPB group and the thoracic epidural analgesia (TEA) group. The primary outcome of this study was analgesic drug dosage and the secondary outcome was numerical rating scales (NRSs) between the two groups. There was no significant difference between the two groups in terms of demographic, preoperative clinical evaluation, or surgical characteristics (P > 0.05). The catheter duration in the TEA group was significantly shorter than that in the ESPB group (P < 0.05), while the hospitalization time in the ESPB group was significantly shorter than that in the TEA group (P < 0.05). In terms of oral morphine equivalent comparison, the required dose of the TEA group was lower than that of the ESPB group on the 1st and 2nd day after the operation (P < 0.05), and there was no statistical difference between the two groups on the 3rd and 4th day after the operation (P > 0.05). The number of patients with an S-NRS ≥ 7 and D-NRS ≥ 7 in the TEA group at day 1 was lower than that in the ESPB group (P < 0.05). There was no significant difference between the two groups at other time points (P > 0.05). An ultrasound-guided ESPB used in Nuss surgery for children with funnel chest can provide good analgesia for surgery and shorten the postoperative rehabilitation and hospitalization time of patients. It is a safe and effective alternative to TEA.

MPFL RECONSTRUCTION, USING FASCIA LATA AS AN AUTOGRAFT, AFTER FAILED PROXIMAL AND DISTAL PATELLOFEMORAL REALIGHMENT PROCEDURES. REPORT OF TWO CASES

Understanding all the technical features and functions associated with medial patellar ligament reconstruction (MPFL) with autograft will make restoration more effectual, limiting complications associated with its non-anatomical placement. We describe in this study the cases of two girls aged seven and thirteen who underwent successful MPFL reconstruction after failed proximal and distal patellofemoral realignment surgeries they had previously undergone to treat recurrent patellar dislocation. The modified Cincinnati and Kujala score were used for the preoperative and postoperative clinical evaluation of the two girls. In the final reassessment of the two girls, seven years post-operatively for the seven-year-old girl, and three years post-operatively for the thirteen-year-old girl, the modified Cincinnati score and the Kujala score were increased significantly. The restoration of the MPFL is a justified surgical method for an effective outcome of the reestablishment of patellar stability in skeletally immature patients who underwent less successful surgeries in the past.

Clinical presentation and management modalities of gallbladder cancer in Sudan: A single-center study.

Gallbladder cancer (GBC) is a rare and highly aggressive malignancy characterized by late presentation of nonspecific symptoms, poor curability, and high mortality. The gold standard for effective treatment depends on early detection and surgical excision. Hence, the aim of this study was to determine the patterns of clinical presentation and management modalities to reach excellent practice. A retrospective study was conducted during the period from May 2021 to April 2022 at Ibn Sina specialized hospital, Khartoum, Sudan, on 50 patients with GBC who underwent a preoperative clinical and radiological evaluation to enable the use of appropriate surgical and oncological approaches. GBC was more prevalent in females in this series where all had GBC (68%), in the ratio 2:1. Distribution of patients according to age ranged between 61 and 75 years, representing 44% of patients. Abdominal pain, nausea, and vomiting were present in 40% of patients. Fifty-six percent of patients resided in urban areas. Transabdominal ultrasound (TUS) with CT scan diagnosed GBC in 54% of patients. GBC was metastatic (stage IV) in 52% of patients. Based on preoperative decision by a multidisciplinary team (MDT), 62% of patients had palliative nonsurgical oncological treatment. Histopathological analysis of the resected GBC showed adenocarcinoma in 74% of cases. The inoperable patients (42%) were treated palliativelly with endoscopic retrograde cholangiopancreatography/systemic chemotherapy. Finally, the overall mortality rate was 56%. Accurate early clinical diagnosis and advanced radiological modalities with curative surgical approaches including clear surgical resection margins and systemic oncological therapies will potentially help in improving GBC survival outcomes.

Atypically Located Hydatid Cyst Cases: Four Unusual Case Reports

Hydatid cysts are frequently located in liver (65-70%) and lungs (25%). The disease is usually asymptomatic when located in the extrahepatic regions. Sometimes, diagnosis can be established by observing germinative membrane, rockwater, or daughter vesicles during the operation.. A 41-year-old female patient applied with the complaint of intermittent left inguinal pain. Echinococcus Indirect Hemagglutination (IHA) test was positive. In the ultrasonographic examination, a hypoechoic area was observed in the posteromedial of the left femoral head.. A 56-year-old female patient, applied with the complaints of intermittent nausea, vomiting, and epigastric pain. She had a history of surgery for liver hydatid cyst 15 years ago and for lung hydatid cyst 10 years ago. IHA test of the patient was positive. The lesion involving septation and accompanied by calcifications around the cyst was reported as a hydatid cyst at dynamic CT for pancreas and upper abdominal MRI. A 22-year-old female patient applied with perianal pain complaint. Drainage was planned for the patient who had a pre-diagnosis of perianal abscess. Tissues similar to the hydatid cyst membrane were excised together with purulent fluid. The patient was diagnosed with hydatid cyst after the pathology result was reported “as compatible with hydatid cyst”. A 32-year-old female patient had a non-metabolic adrenal subcapsular cyst (hydatid cyst?) in the right adrenal gland on ultrasonography performed for abdominal pain. In abdominal tomography, a “cystic mass compatible with hydatid cyst located in the adrenal gland in the upper pole of the right kidney” was reported. IHA test of the patient was negative. Hydatid cysts located in the perianal region and muscles have been reported as atypical localizations in the literature, and some of them were diagnosed as a result of preoperative clinical evaluation and radiological imaging. Some were diagnosed as a result of pathological examination after the operation. Surgical treatment is an option in suitable cases, and the definitive diagnosis can be established by pathology. Consequently, it should be considered that cystic lesions detected in the patients living in endemic regions can be extrahepatic hydatid cyst that is localized in different anatomical regions.

Does Notching Along the Nasal Velar Surface During Nasopharyngoscopy Predict Discontinuity of the Underlying Levator Veli Palatini Muscle?

Thirty-seven patients who presented with hypernasality and/or audible nasal emission on speech evaluation and completed nasopharyngoscopy and velopharyngeal MRI study as part of their preoperative clinical evaluation.

From Sub-Pectoral to Pre-Pectoral Implant Reconstruction: A Decisional Algorithm to Optimise Outcomes of Breast Replacement Surgery

Innovations and advancements with implant-based breast reconstruction, such as the use of ADMs, fat grafting, NSMs, and better implants, have enabled surgeons to now place breast implants in the pre-pectoral space rather than under the pectoralis major muscle. Breast implant replacement surgery in post-mastectomy patients, with pocket conversion from retro-pectoral to pre-pectoral, is becoming increasingly common, in order to solve the drawbacks of retro-pectoral implant positioning (animation deformity, chronic pain, and poor implant positioning). A multicentric retrospective study was conducted, considering all patients previously submitted to implant-based post-mastectomy breast reconstruction who underwent a breast implant replacement with pocket conversion procedure at the University Hospital of Udine-Plastic and Reconstructive Surgery Department-and "Centro di Riferimento Oncologico" (C.R.O.) of Aviano, from January 2020 to September 2021. Patients were candidates for a breast implant replacement with pocket conversion procedure if they met the following inclusion criteria: they underwent a previous implant-based post-mastectomy breast reconstruction and developed animation deformity, chronic pain, severe capsular contracture, or implant malposition. Patient data included age, body mass index (BMI), comorbidities, smoking status, pre- or post-mastectomy radiotherapy (RT), tumour classification, type of mastectomy, previous or ancillary procedures (lipofilling), type and volume of implant used, type of ADM, and post-operative complications (breast infection, implant exposure and malposition, haematoma, or seroma). A total of 31 breasts (30 patients) were included in this analysis. Just three months after surgery, we recorded 100% resolution of the problems for which pocket conversion was indicated, which was confirmed at 6, 9, and 12 months post-operative. We also developed an algorithm describing the correct steps for successful breast-implant pocket conversion. Our results, although only early experience, are very encouraging. We realized that, besides gentle surgical handling, one of the most important factors in proper pocket conversion selection is an accurate pre-operative and intra-operative clinical evaluation of the tissue thickness in all breast quadrants.

Surgical Treatment of Monteggia-Like Lesions With a Modified Boyd Approach.

Monteggia-like lesions are rare injuries in adults that include a wide spectrum of complex fracture-dislocations of the proximal ulna and radius. In this retrospective study, we performed a modified Boyd approach and a standard surgical protocol for the treatment of these lesions. Our aim was to evaluate the results of the operative treatment for patients with Monteggia-like lesions, using a modified Boyd approach. We present a retrospective study of 14 patients who underwent surgical treatment for Monteggia-like lesions. Preoperative clinical and radiological evaluation was performed. In 5 cases radial head prosthesis was placed, and in 3 cases the radial fracture was stabilized with the use of interfragmental screws. Regarding the proximal ulnar fracture, ORIF-anatomical plate and ORIF-straight plate was used in 12 and 2 cases, respectively. Average clinical follow up was 16.9 months. Postoperatively, the mean Mayo Elbow Performance score was 83.4 points (range 70-100) and the mean visual analog scale was 1.7 (range 0-14). Mean flexion and loss of extension were 122.1° (range 80°-140°) and 21.4° (range 5°-40°), respectively. Mean supination of the forearm was 66.8° (range 50°-80°) and the mean pronation was 67.5° (range 60°-75°). Heterotopic ossification was observed in 3 patients (21.4%) and 1 patient developed stiffness (7.1%). The patient who developed stiffness underwent reoperation for plate removal and arthrolysis, with satisfactory results. The surgical treatment of Monteggia-like lesions in adults remains a challenge. In the present study, the use of a standard surgical protocol, with a modified Boyd approach, successfully restores the movement and stability of the elbow, with a low complication rate.