Preoperative Diagnostic Approach Research Articles

Extrarenal Pyelocalyceal System or Extrarenal Calyces: A Case Series and Literature Review

ABSTRACT Extrarenal pyelocalyceal system or extrarenal calyces, a congenital anomaly, is identified when it presents with pelviureteric junction obstruction. It is elusive to preoperative diagnosis and was identified only intraoperatively in all published pediatric cases. Experience gained by managing a series of cases and a literature search has guided us to evolve a preoperative diagnostic approach, a pyelotomy technique, and a practical classification of the EPS. During the period from 2003 to 2023, four cases with six kidneys of the EPS including three kidneys of the polar extrarenal infundibulum and calyces, a variant of EPS involving only upper or lower pole of the kidney, were seen. Successful pyeloplasty was performed in five of the six kidneys for PUJO using a careful pyelotomy technique. Characteristic “garden rake” X-ray sign was seen in intravenous urogram or retrograde pyelogram, contrast-enhanced computerized tomogram, or magnetic resonance imaging (MRI) of the abdomen in three kidneys. Retrograde pyelogram, CECT, or MRI of the abdomen identified the polar variant in three kidneys. Late-onset PUJO was seen in one case. Four cases with PUJO presented with significantly reduced renal function. One showed postoperative deterioration to nonfunction despite good drainage. A preoperative diagnostic approach, a pyelotomy technique for pyeloplasty, and a classification of the EPS are evolved by the authors. Progressive loss of function and late-onset obstruction mandate a renal-sparing pyeloplasty approach and follow-up.

Association of psoriatic arthritis and temporomandibular joint ankylosis

Introduction: Psoriasis is a chronic autoinflammatory skin disease affecting 2–3% of global population, of whom 30% are known to have psoriatic arthritis. Psoriatic arthritis is a systemic disease involving the dermatosis along with inflammatory joint involvement. The association of psoriatic arthritis (PsA) and its clinical and radiological manifestations with the temporomandibular joint have been limited. Case Report: This case report aims to showcase the involvement of the temporomandibular joint with a long standing systemic psoriatic arthritis. Impaired quality of life is the primary concern which this case report attempts to highlight by enumerating the association of psoriatic arthritis with accurate diagnosis of temporomandibular joint ankylosis. Conclusion: The ambiguity in the nature of presentation of PsA can account for its lack of recognition when affecting the temporomandibular joint. A consistent preoperative evaluation and diagnostic approach toward the affected joint shall improve the patient’s quality of life.

OVARIAN MASSES IN WOMEN: A RETROSPECTIVE ANALYSIS IN TERTIARY CARE CENTER

Objective: To describe the presenting signs and symptoms, clinic-pathological findings of ovarian masses and to establish diagnostic value of clinical examination, ultrasonography and its correlation with histopathological diagnosis.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Combined Military Hospital, Rawalpindi Jun 2017 May 2018.
 Methodology: Women who underwent surgery for ovarian masses were included. Data was collected from hospital records including; age, presenting symptoms, duration of symptoms, changes in menstrual cycle, and the results of the physical examination. The preliminary diagnoses as well as the final diagnosis were noted.
 Results: A total of 83 patients with ovarian masses, who underwent surgery over the period of a year, were included. The most common symptom was abdominal pain in 56 (67.5%) followed by abdominal distention 9 (10.8%), dysmenorrhea 8(9.6%). When both clinical and sonological diagnosis were combined, the overall sensitivity, specificity, positive and negative predictive value for diagnosis and discriminating benign and malignant ovarian neoplasms were 87.5%, 96.7%, 70%, and 98.88%, respectively.
 Conclusion: In this study most, common symptom was abdominal pain both in benign and malignant ovarian masses. Whereas, abdominal distention was more common in malignant masses. Preoperative diagnostic approach should always include careful history taking, physical examination, imaging and evaluation of tumor markers. Early detection, thorough treatment and regular follow-up are the need of time to reduce the morbidity and mortality.

Colon cancer in the older population

Fifty percent of new diagnoses of colorectal cancer are made in patients aged over 70 years, and 25% are aged 80 years or over. Older patients tend to have locally advanced colon cancer, with negative lymph nodes and without distant me­tastasis. Frequently the colon cancer is located on the right side. There is still a belief that older patients can not manage curative treatment regimens. This is based on the results of older studies showing higher rates of short-term morbidity and mortality. At present, we are observing significant improvements in the outcomes of older patients with colon cancer in high volume centers. This could be due to better preoperative staging, increased use of minimally invasive techniques, better anesthesiology and perioperative care, awareness of complications, expertise and high-volume care. A standardized pre-operative diagnostic approach, individualized surgical technique selection and tailored postoperative care are essential for the successful treatment of older patients. Furthermore, counseling and shared decision-making should be based on modern insights in surgical outcomes rather than outdated data.

Preoperative visualization of neurovascular contact with 3D-FIESTA combined with 3D-TOF MRA to guide microvascular decompression surgery planning

Background:Neurovascular compression syndromes including trigeminal neuralgia (TN) and hemifacial spasm (HFS) are caused by neurovascular conflicts at the root entry zone of the corresponding cranial nerves in the posterior fossa. Microvascular decompression (MVD) is the best choice for the treatment of TN and HFS. An accurate delineation of the responsible vessel could decrease the rate of possible operative complications such as nerve paresis.Methods:In this study, three-dimensional fast imaging employing steady-state acquisition (3D-FIESTA) and three-dimensional time-of-flight magnetic resonance angiography (3D-TOF MRA) were performed on 113 patients with TN or HFS. The imaging data were compared to the intraoperative findings and the accuracy of the data was calculated among the different responsible blood vessels and disease types. The accuracy of the data among different genders, disease durations, disease sides, and disease types was also calculated to identify the target patients for the preoperative diagnostic approach with 3D-FIESTA combined with 3D-TOF MRA.Results:The accuracy of detection with the imaging was above 75% in cases with single-vessel compression. Among these, the accuracy of the preoperative imaging result was the highest when the lesions were in the superior cerebellar artery (SCA; 91.1%). In cases of multiple-vessel compression, however, the coincidence between the preoperative and intraoperative results was only 30.0%. In most of the cases of TN, the responsible blood vessels were in the SCA, and the accuracy in the SCA reached 94.9%. In HFS patients, the responsible blood vessels were in the anterior inferior cerebellar artery (AICA) and posterior inferior cerebellar artery (PICA), and the accuracy was 86.8% and 90.0%, respectively. The differences in the accuracy of the data among different genders, disease durations, disease sides, and disease types were not statistically significant.Conclusion:This study verified the clinical instructional value of 3D-FIESTA combined with 3D-TOF MRA in MVD, and showed that this preoperative examination is reliable for all genders, disease durations, disease sides, and disease types.

Oncogeriatrics (part 4.) Pre-operative assessment of elderly patients with cancer

Older patients comprise a highly heterogeneous group, and chronological age, comorbidities, or the type of surgical pro­cedure performed cannot adequately describe the risk of adverse post-operative outcomes. Therefore, current routine pre­-operative assessment also cannot adequately identify patients at risk. The Comprehensive Geriatric Assessment, the mean life expectancy and the treatment goals of a patient must be included in the pre-operative evaluation. The Comprehensive Geriatric Assessment helps to determine the primary status of an older patient, to diagnose frailty syndrome and to identify how to optimize a patient’s condition before surgery. Surgery is one of the primary triggers for disability in older patients. In this age group, being independent is more important than prolonging life. This is particularly true in patients with frailty syndrome, or decreased physiological reserves, which arise from cumulative deficits in several physiological systems and result in a diminished resistance to stressors. Therefore, a standardized pre-operative diagnostic approach, individualized surgical technique selection and tailored post-operative care are essential for successful treatment of elderly patients.

Acute mesenteric ischemia: a review of 50 cases

Background: Acute mesenteric ischemia is a rare but highly lethal cause of abdominal pain. Diagnosis should be prompt to ensure early treatment and avoid progression of the disease. The aim of the study was to describe the population presenting with acute mesenteric ischemia submitted to surgery, evaluate their outcome and determine possible predictors of mortality.Methods: Retrospective analysis of all patients who underwent surgery due to mesenteric ischemia between May 2013 and January 2015. A total of 50 patients were included. Pre-operative patient risk factors, diagnostic and surgical approach, post-operative complications and outcome were analysed. Statistical analysis was performed using SPSS v. 20. Univariable analysis was performed using T student and chi square tests.Results: Mean age was 79 years. Most patients (n=43) had cardiovascular risk factors. Clinical and laboratory studies findings were non-specific. During surgery, 28% were found to have extensive ischemia. Exclusive exploratory laparotomy was done in 11 cases due to extensive ischemia. Thrombectomy was performed in 6 cases. Eleven patients were submitted to reoperation. In-hospital mortality was 68% (n=34). Patients who died had more frequently systemic findings and extensive ischemia. Patients with extensive vs. segmental ischemia were also compared and no statistically significant differences regarding preoperative findings were found. Mortality was significantly higher in patients with extensive ischemia.Conclusions:Timely diagnosis and treatment are essential to improve the outcome of AMI but tools to perform this are still lacking. Mortality remains high, especially when ischemia is extensive at the time of surgery.

P07-T Presurgical investigation of sexual behaviour of an epileptic patient

Introduction Periventricular nodular heterotopy is frequently associated with drug resistant, mainly temporal lobe epilepsy. Patients and methods We report a young female patient with frequent focal seizures with sexual behaviour. MRI revealed right hemispherial multiplex periventricular nodular heterotopy most of them arround amygdala-hippocampus and the occipital horn of the lateral ventricle. Based on the noninvasive diagnostic steps, depth electordes were implanted with robot assisted stereotactic surgical procedure. Results During SEEG monitoring beside identifing posterior temporal seizure onset zone, the sympotmatic amygdalar involvement was also recognized with typical behavioral pattern on video-EEG. Discussion: Based on the seizure semiology, the stereo-EEG results, neuroradiologic and neuopsychologic findigs intraoperative electrocorticography guided righ temporal lobe resection was performed. One year after the operation, the patient is seizure free and her quality of life improved. Conclusion Multimodal preoperative diagnostic approach including both invasive and non-invasive methods should lead to succesful outcome in therapy resistant epilepsy with multifocal cortical developmental malformations. Besides therapeutic aspects, SEEG offers unique opportunity in understanding complex neuro-pathophysiological mechanisms.

Breast implant-associated anaplastic large-cell lymphoma.

Key Clinical MessageIn patients with suspected breast implant–associated anaplastic large‐cell lymphoma, cytologic evaluation of fine‐needle aspirate specimens from the peri‐implant seroma, together with flow cytometric immunophenotyping and immunohistochemistry, represents a suitable preoperative diagnostic approach when planning for surgical management.

Fine-needle aspiration with selective use of core needle biopsy of major salivary gland tumors.

Preferential use of fine-needle aspiration (FNA) versus core needle biopsy (CNB) for distinguishing benign from malignant major salivary gland tumors is highly debated. The main disadvantage of FNA is lower sensitivity, whereas arguments against CNB include use of a larger bore needle and greater risk of complications. The aim of this study is to evaluate our experience performing ultrasound-guided (UG) FNA with selective use of CNB based on preliminary cytopathology, and to determine whether our preoperative diagnostic approach is more sensitive and specific than FNA alone-and at least as sensitive and specific as CNB alone. Retrospective review of UG needle biopsy sampling of lesions arising in or around parotid and submandibular glands. Ultrasounds of 141 needle biopsies were identified. Patient/lesion/needle biopsy characteristics, preliminary cytopathology, final pathology, imaging studies, and subsequent clinical course and treatment were documented. Needle biopsies performed according to our protocol provided results that guided clinical decision making in 125 of 135 cases, 92.6% (95% confidence interval [CI], 86.8%-96.4%) of the time. Using 41 cases that had histologic verification, sensitivity was 100% (95% CI, 79.6%-100%), and specificity was 92.3% (95% CI, 75.9%-97.9%) for detecting malignancy. We definitively characterized 120 lesions as benign (84) or malignant (36). Preoperative needle biopsy diagnoses allowed clinical management to progress 92.6% of the time. The protocol of FNA with selective use of CNB may potentially reduce patient exposure to risks associated with CNB without the tradeoff of lower sensitivity seen with FNA. 4. Laryngoscope, 127:2522-2527, 2017.

Study of Ovarian Masses in Young Females: A Hospital Based Study

Objective: The purpose of this study was to analyze various clinical presentations, and the management of ovarian lesion in the young girls.Materials and methods: All the patients within the age limit of 20, who were admitted in the department of obstetrics and gynecology in NGMC between October 2011 to September 2015 with a diagnosis of an ovarian mass were analyzed. Age, presenting symptoms, duration of symptoms, physical examination findings and radiological imaging results were obtained. Ultrasonography was the gold standard for the diagnosis. The preliminary and final diagnoses were recorded.Results: 25 patients were identified, diagnosis of functional cyst was accounted for 9, 5 were hemorrhagic cyst and chocolate cyst and neoplastic tumors were accounted for 11 patients during the same period. The most common presenting complaint was abdominal pain. On physical examination 8 girls had abdominal tenderness and 15 patients had palpable masses.Conclusion: Ovarian masses presenting with abdominal complaint can mimic other diseases. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of the patient includes careful history taking, physical examination, imaging and evaluation of biological markers in selective cases. Conservative surgery is advocated to preserve the fertility potential of these patients.JNGMC Vol. 13 No. 2 December 2015, Page: 38-41

“Typical” contrast oesophagogram: Are we really prepared to face its perpetual diagnostic challenges?

The authors describe a case of a 35-year-old female with a 15-month history of progressive dysphagia. It was based on preoperative oesophagogram and oesophagogastroduodenoscopy, but their preoperative diagnosis was wrong. The authors discuss the possibilities of diagnostic challenges. Α wrong preoperative diagnostic approach was ascertained during laparoscopy, where the patient was scheduled for laparoscopic Heller’s cardiomyotomy.

The Evaluation of Preoperative Diagnostic Approach to Solitary Pulmonary Nodule with Solid Structure

DOI: 10.4328/JCAM.3560 Received: 11.05.2015 Accepted: 23.05.2015 Publihed Online: 24.05.2015 Corresponding Author: Tumay Ozgur, Pathology Department, Mustafa Kemal University, School of Medicine, 31100, Serinyol, Hatay, Turkey. T.: +90 3262291000-3329 F.: +90 3262455654 E-Mail: ozgurtumay@yahoo.com Ozet Prostat kanseri erkeklerde en sik gozlenen prostat malignensilerindendir ve duktal adenokarsinom klinik ve histolojik ozellikleri ile belirgin patolojik bir subtipidir. Yetmis alti yasinda Kronik lenfositik losemi/Kucuk hucreli lenfositik lenfomali (KLL/SLL) erkek hasta alt uriner sistem semptomlari ile hastanemize basvurdu. Son prostat spesifik antijen seviyesi (PSA) 26 ng/ml ile bir cok transrektal ultrasound rehberligindeki biopsiler uygulandi ve patoloji raporlari benign prostat hiperplazisi ve non-spesifik prostatit olarak sonuclandi. Semptomlarin devam etmesi uzerine prostata transuretral rezeksiyon uygulandi. Materyalin patolojik degerlendirilmesinde benign hiperplazik prostat dokulari arasinda stromasi olmayan adenokarsinom odaklari gozlendi. Tumor 4+4 Gleason patern skoru ile duktal adenokarsinom olarak tani aldi. Metastaza bagli lomber vertebrada kemik sintigrafisinde aktivite tutulumu vardi. Bilgisayarli tomografide onceki KLL/SLL ‘ye bagli inguinal ve sag iliak lenfadenopati izlendi. Total androjen kisitlama tedavisi ve bilateral orsiektomi uygulandi. 3 ay sonra biokimyasal ve radyolojik goruntuleme sonuclarina gore radyoterapi tedavisi planlandi. Duktal adenokarsinoma konvansiyonel adenokarsinomdan farkli klinik davranisi olan prostatin nadir bir subtipidir. Diger yandan KLL/SLL takibi yapilan bir hastada sekonder bir malignensi olarak ortaya cikmasi olguyu degerli kilmaktadir.

Preoperative Diagnostic Approach in Patients with Medically Refractory Epilepsy

Preoperative Diagnostic Approach in Patients with Medically Refractory Epilepsy

Ovarian Tumors in Children and Adolescents—A Clinical Study of 52 Patients in a University Hospital

Study Objective To review the clinical presentation of ovarian tumors in children and adolescents treated at the University of Dammam and King Fahad University Hospital. Design Data of the patients was noted retrospectively from the hospital medical records regarding age, presentation, diagnosis, treatment, and outcome. Setting The study was carried out in the Ob/Gyn department at King Fahad Hospital of Dammam University, Saudi Arabia between January 1985 and December 2009. Participants There were 52 patients between 6 and 20 years of age who presented with an ovarian tumor during the study period. Intervention Preoperative diagnostic approach included history, physical examination, ultrasonography, radiological examination, tumor markers, operative treatment, and histopathological examination of the tumor. Chemotherapy was given to patients where indicated. Results The main presenting symptom was abdominal pain in 30 (58%) patients. Of the neoplastic tumors, 87% were germ cell tumors, of which 73% were benign while 13% were malignant. Operative procedures included 48 (92%) exploratory laparotomies and 4 (8%) laparoscopic resections. Ovarian cystectomy was done in 23 (44%) patients and salpingoophorectomy in 28 (54%) patients. Of the 7 (13%) patients with malignant tumors, five received postoperative chemotherapy. Three patients with malignancy died in the series. Conclusion Early diagnosis of ovarian masses in young girls is important. Since most of these masses are benign, operation should be designed to optimize future fertility, while the treatment of malignant tumors would involve complete staging, resection of the tumor, postoperative chemotherapy when indicated, to give the patient a chance for future childbearing.

Multimodality Imaging Of Giant Prolapsing Left Atrial Myxoma

Through a case of a very large left atrial myxoma diagnosed in a 53-year old woman, we feature the complementary value of multimodality imaging. Two-dimensional echocardiography continues to be the principal imaging modality for intracardiac masses due to its accessibility and ability to provide basic information on mass morphology, position, and mobility. Real-time three-dimensional echocardiography offers more precise assessment of tumor size and attachment. Cardiac magnetic resonance allows superior tissue characterization, particularly important in differentiating a myxoma from a thrombus. Appropriate use of these various non-invasive imaging modalities is a safe and comprehensive preoperative diagnostic approach for patients with intracardiac masses.

Multimodality Imaging of Giant Prolapsing Left Atrial Myxoma

Through a case of a very large left atrial myxoma diagnosed in a 53-year old woman, we feature the complementary value of multimodality imaging. Two-dimensional echocardiography continues to be the principal imaging modality for intracardiac masses due to its accessibility and ability to provide basic information on mass morphology, position, and mobility. Real-time three-dimensional echocardiography offers more precise assessment of tumor size and attachment. Cardiac magnetic resonance allows superior tissue characterization, particularly important in differentiating a myxoma from a thrombus. Appropriate use of these various non-invasive imaging modalities is a safe and comprehensive preoperative diagnostic approach for patients with intracardiac masses.

Ovarian masses during adolescence: clinical, ultrasonographic and pathologic findings, serum tumor markers and endocrinological profile

This retrospective study was undertaken to assess the epidemiological and clinical features, laboratory findings, preoperative work-up, surgical treatment and pathologic findings in adolescents with ovarian cysts. All adolescents who were referred to our institution and had been operated on because of a diagnosed ovarian mass, from January 1997 to June 2003, were included in this study. Forty-four cases of women with an ovarian mass were retrospectively analyzed. These patients, aged between 12 and 21 years, had 47 ovarian masses (three patients had bilateral lesions), of which 49% were non-neoplastic and 51% were neoplastic. Of the neoplastic lesions, 62.5% were germ cell tumors, 20.8% were epithelial and 16.7% were sex cord–stromal tumors. Of the neoplastic tumors, 95.8% were benign while 4.2% were malignant. Procedures included 30 operative laparoscopies (68.2%) and 14 exploratory laparotomies (31.8%). Simple excision of the ovarian cyst was performed in 39 cases (88.6%). According to our study, most of the adolescents with an ovarian cyst underwent an operation because of a neoplastic lesion. The majority of ovarian tumors occurring in adolescents are non-epithelial in origin, and germ cell tumors are the most common histological type. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of these patients should always include careful history taking, physical examination, imaging and evaluation of serum assays. Gynecologists who care for young girls must be familiar with the differential diagnosis of ovarian masses whose surgical treatment should be conservative when appropriate, so that hormonal status and future fertility are not compromised in this group of patients.

Clinical Manifestations of 15 Cases of Pulmonary Sequestration

Background : Pulmonary sequestration is a rare congenital malformation, which is manifested by formation of nonfunctioning lung tissue lacking normal communication with the tracheobronchial tree. The preoperative diagnostic rate has been relatively low, and without consideration of pulmonary sequestration, unexpected bleeding from aberrant vessels may be a serious problem during the operation. The purpose of our study is to describe the clinical features of pulmonary sequestration based on a review of 15 cases treated by operation. Method : Fifteen patients with pulmonary sequestration who had undergone surgical treatment from 1991 through May 1996 at Yongdong Severance Hospital and Severance Hospital were reviewed retrospectively. Results : The mean age of the patients was 22.5 years (range 5~57), and male to female ratio was 9 : 6. Clinical presentations varied from recurrent respiratory infections such as fever, cough, and sputum or chest pain to no symptom. The chest simple X-rays showed multicystic shadow(10/15) and solid mass-like shadow(5/15). The chest CT scans, done in twelve cases, showed multicystic lesion with or without lung infiltration(8/12), solid mass-like lesion(4/12), The chest MRIs, done in three cases, revealed the aberrant arteries originating from descending aorta(2/3). Aortograms, done in four cases, showed the aberrant arteries originating from descending thoracic aorta(2/4), abdominal aorta(I/4), and intercostal artery(1/4). and the venous returns were via the pulmonary veins. Pulmonary sequestration was considered preoperatively in six patients of fifteen. Other preliminary diagnosis were lung tumor(3/15), lung abscess(21/15), bronchiectasis(2/15), and mediastinal tumor(2/15). In the operative findings, twelve cases were of intralobar type and three cases of extralobar type. The left lower lobe was most often affected(9/15) and one extralobar sequestration was in the pericardium. The aberrant arteries originated from descending thoracic aorta(6/15), abdominal aorta(1/15), internal thoracic arteries (2/15), intercostal artery(1/15), pericardiophrenic artery(1/15), but in four cases, the origins could not be defined. There was no mortality or complication postoperatively. Conclusion : In our study, preoperative diagnostic rate was relatively low, and clinical features were similar to previous reports. Preoperative vigorous diagnostic approach including aortography is strongly advocated not only for its diagnostic value, but also for accurate localization of the aberrant vessels, which is major concern to surgical procedure.

Seven-year experience of noninvasive preoperative diagnostics in children with congenital heart defects: comprehensive analysis of 2,788 consecutive patients.

The spectrum of patients operated on without preoperative catheterization and angiography, the accuracy of echocardiographic diagnosis and its impact on the results of surgical treatment were prospectively assessed in 2,788 children consecutively operated for congenital heart defects (CHD) between 1986 and 1992. The overall percentage of surgery based solely on noninvasive preoperative examination increased from 63% in 1986 to 81% in 1990 and decreased to 72% in 1992. There were no differences in the preoperative diagnostic approach between groups of newborn, infants and children. A high percentage of patients with patent ductus arteriosus (96.5%), atrial septal defect (94%), incomplete atrioventricular septal defect (88.6%), ventricular septal defect (86.3%), coarctation of the aorta (80.2%) and total anomalous pulmonary venous connection (79.3%) was referred for surgery without prior invasive examination, while a lower percentage was found in univentricular heart (48.4%), pulmonary atresia (34.6%) and double outlet right ventricle (27.7%). More patients with pulmonary and tricuspid atresia were catheterized before complete repair compared to those who underwent palliative surgery (p < 0.01 and p < 0.0001, respectively). The echocardiographic diagnosis was correct in 96% of patients. Two patients of those with incomplete preoperative diagnosis died early postoperatively, both with missed apical ventricular septal defect. One with tetralogy of Fallot died after reoperation, the other with persistent truncus arteriosus due to sepsis. When the echocardiographic findings are in full agreement with the clinical status, physical examination, ECG and chest X-ray, we recommend cardiac surgery without prior catheterization in many patients with CHD.