Preoperative Radiological Evaluation Research Articles

Can Sacropelvic Fixation Improve Outcome of Long-Segment Lumbar Spine Fusion in Patients with Degenerative Lumbar Spine Disease?

Background Data: Posterior spinal fusion has been more and more used for management of degenerative disorders of the lumbosacral spine. Long-segment fixation of three or more motion segments extending down to the sacrum has been associated with loosening or failure of S1 screws. Purpose: Comparison between fixations extending to S1 and those to S2 (S2-alar-iliac screws) with sacropelvic fixation in the management of multilevel lumbar spinal canal stenosis. Study Design: Prospective controlled cohort study. Patients and Methods: We recruited 45 patients suffering from lumbar spinal canal stenosis of 3 or more levels including 16 revision cases in the whole group. In 23 patients, posterior lumbar fusion extended to S1 and in 22 fixations extended to S2. Pre- and postoperative clinical evaluation included Visual Analogue Scale (VAS) for back pain and Oswestry Disability Index (ODI). Preoperative radiological evaluation included plain X-ray and MRI. Postoperative clinical evaluation included VAS and ODI and radiological evaluation included X-ray and CT. The mean follow-up duration was 14.1±1.7 months (range, 12–24) in S1 group and 14.3±1.9 months (range, 12–24) in S2 group. Results: The mean VAS improved from 8.1±0.8 to 4.9±0.9 in S1 group and from 7.7±1.2 to 1.95±0.79 in S2 group. The mean ODI improved from 77±10.5 and 76.8±10.9 to 45.9±7.3 and 29.5±8.4 in S1 and S2 groups, respectively. Two dural tears were repaired intraoperatively with no postoperative consequences. Seven cases in S1 group had loosening of S1 screw that was evident at 6-month follow-up. Conclusion: Sacropelvic fixation in the form of S2-alar-iliac screws provides a significantly more rigid construct, decreasing the incidence of loosening of S1 screws and improving the overall outcome in patients treated with long lumbar fusion. (2019ESJ199)

Analysis of Treatment Outcome Associated with Pre-Operative Diagnostic Accuracy Changes and Dental Treatment Timing in Odontogenic Sinusitis Involving Unilateral Maxillary Sinus

Background and Objectives Unilateral sinusitis is caused by various factors. Odontogenic sinusitis; especially, is different from non-odontogenic sinusitis in clinical features and prognosis. The purpose of this study is to evaluate the prognosis of odontogenic sinusitis in accordance with the changes in diagnostic accuracy over time and the timing of dental treatment. Subjects and Method 195 patients who underwent endoscopic sinus surgery for unilateral sinusitis within the interval from 2006 to 2017 were reviewed to analyze the etiologies and clinical characteristics. Preoperative CT was assessed to identify patients who had not been diagnosed with odontogenic sinusitis in the past. In the unilateral bacterial sinusitis, we identified changes in incidence, diagnostic accuracy, and outcome in the odontogenic sinusitis. We divided odontogenic sinusitis patients into three groups: preoperative and intraoperative dental treatment group, postoperative dental treatment group, and untreated group. Then we analyzed the difference in prognosis of these three groups. Results The total number of patients with odontogenic sinusitis was 86 (44%), which accounted for about 36% until 2011, but increased to about 48% after 2013. From 2006 to 2011, there were 15 cases of missed diagnosis of odontogenic sinusitis, but there was 1 case in 2012 and no cases since 2013. The treatment outcome of unilateral bacterial sinusitis was significantly increased from 84.1% before 2011 to 96% after 2012. The success rate was 97.1% in the case of accurate diagnosis of odontogenic sinusitis, but the success rate was 43.8% in case of missed diagnosis. In odontogenic sinusitis, the success rate was low when dental treatment was not performed. However, there was no difference in success rate among different dental treatment timings. Conclusion The incidence of odontogenic sinusitis has steadily increased over the last decade. The prognosis has been improved by appropriate treatment under accurate diagnosis through preoperative examination and radiological evaluation. There was no difference in the prognosis of odontogenic sinusitis according to the dental treatment time. Therefore, it is a good choice for tooth preservation to have an endoscopic sinus surgery first and then decide the dental treatment timing. Key words: Chronic rhinosinusitis ㆍ Odontogenic sinusitis ㆍ Treatment strategy

P2.05-17 Preoperative Identification of the Left Common Pulmonary Vein for Safe Video-Assisted Lobectomy

The pulmonary veins (PVs) display many anatomical variations. Some anomalies, especially the common trunk of the left PV, are associated with serious surgical morbidity for patients undergoing lung surgery. Compared with thoracotomy, video-assisted thoracic surgery (VATS) has a limited view of the surgical field, thus thoracic surgeons must be familiar with anatomical variations in the PVs. We aimed to investigate the anatomical variants of the left PVs using three dimensional (3D)- computed tomography (CT) images. We reviewed anatomical variations of the left PVs of 156 consecutive patients who had undergone surgical pulmonary resection at our institution, using the multidetector contrast-enhanced CT. The common trunk was defined anatomically as the presence of a single ostium at the point of reflection of the parietal pericardium along the left atrium. We identified the common trunk of the left PV in 11 of the 156 patients (7.1%), and the discrete left lingular vein (V4+5) draining near the inferior PV in 2 patients (1.2%). Of which, 5 had the long common trunk; the length of the common trunk outside the pericardium was equal to or longer than 10mm. Of these 11 patients, 5 were men, 4 had hypertension, 3 had valvular disease, 1 had coronary artery disease, 1 had paroxysmal atrial fibrillation (Paf), and the remaining 7 had no hypertension or structural heart disease. Although the anatomical variants of PV have been related to a higher arrhythmogenic potential, only 1 (9%) patient had postoperative complication of Paf. In 11 cases, 3 had incomplete lobulation and 3 had left lingular pulmonary artery arising from pars mediastinalis. The common trunk of the left PV was accompanied by other variant anatomies, that included; 1) right V6 draining into the superior PV in 3 cases; 2) right superior vein passing dorsal to right main pulmonary artery in 1 case; 3) supernumerary bronchus corresponding to left B7 in 2 cases. We encountered three cases demonstrating a common trunk of the left PV during VATS lobectomy. 3D-CT reconstruction was useful for recognizing such anomalies before surgery and allows safe VATS lobectomy. In surgical findings, the common trunk was located in the normal superior pulmonary vein drained into the left atrium. We should expose this vein adequately and dissect peripherally for confirmation of the common trunk. We conclude that the common trunk of the left PV is not a very rare anomaly and might be accompanied by other variant anatomies. Careful preoperative radiological evaluation of the pulmonary veins is essential to perform safe VATS lobectomy. 3D-CT can provide detailed information for assessing abnormalities of venous return.

Genial tubercle position and genioglossus advancement in obstructive sleep apnea (OSA) treatment: a systematic review

BackgroundTo systematically review the literature for methods to localize the genial tubercle as a means for performing an advancement of the genioglossus muscle.MethodsPubMed, Google Scholar, CRISP, EMBASE, CINAHL, and Scopus were searched from inception through June 16, 2015.ResultsOne hundred fifty-two articles were screened, and the full text versions of 12 articles were reviewed in their entirety and 7 publications reporting their methodology for localizing the genial tubercle. Based upon these measurements and the results published from radiographic imaging and cadaveric dissections of all the papers included in this study, we identified the genial tubercle as being positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandibular border.ConclusionBased upon the results of this review, the genial tubercles were positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandible border. It may serve as an additional reference for localizing the genial tubercle and the attachment of the genioglossus muscle to the mandible, although the preoperative radiological evaluation and the palpation of the GT are recommended to accurately isolate.

Latissimus dorsi transfer for massive posterosuperior rotator cuff tears: what affects the postoperative outcome?

The management of irreparable posterosuperior rotator cufftears (IPSRCTs) in young active individuals is still a challenge. The aim of this study was to evaluate the influence of sex, surgical technique, previous surgical procedures, tear genesis, and presence of a preoperative external rotation lag sign on the functional outcome after latissimus dorsi transfer (LDT) for IPSRCTs. Retrospectively, all patients with IPSRCTs treated with LDT during a 10-year period were followed up. Preoperative evaluation included the visual analogscale (VAS) score, range of motion, and the Constant score (CS). Postoperatively, the VAS score, range of motion, CS, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value were recorded. Preoperative and postoperative radiologicevaluation was performed using the Hamada-Fukuda classification and the acromiohumeral interval. In total, 67 of 79 patients (85%), with a mean age of 63 years, were available for follow-up at 54 ± 28 months. The CS improved from 24 ± 6 points preoperatively to 68 ± 17 points at follow-up (P < .001). Active flexion increased from 83° ± 47° to 144° ± 35°; abduction, from 69° ± 33° to 134° ± 42°; and external rotation, from 24° ± 18° to 35° ± 21°. Postoperatively, the Subjective Shoulder Value was 69% ± 19% and the American Shoulder and Elbow Surgeons score was 76 ± 21. The VAS score decreased from 6.3 ± 1.1 to 1.8 ± 2 (P < .001). Abduction strength increased from 0.4 ± 0.4 kg to 3.6 ± 2.2 kg (P < .001). The acromiohumeral interval decreased from 7.9 ± 2.6 mm to 5.1 ± 2.2 mm, and arthropathy worsened from Hamada-Fukuda stage 1.4 to stage 2.1. The rate of conversion to a reverse prosthesis was 6%. LDT represents a reliable and reproducible treatment option with good clinical midterm results after surgical treatment. Sex, genesis, preoperative presence of an external rotation lag sign, and previous surgical procedures do not affect the overall clinical outcome.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BackgroundPreoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial. MethodsA retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016. ResultsTwo hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m2. Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett’s esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p = < 0.0001) and symptoms were a poor indicator for GERD. ConclusionsPreoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

Comparative evaluation of SPECT/CT and CBCT in patients with mandibular osteomyelitis and osteonecrosis.

Therapy of osteomyelitis and osteonecrosis very often requires surgery. Proper preoperative radiological evaluation of a lesion's localization and extent is a key in planning surgical bone resection. This study aims to assess the differences between single-photon emission computed tomography and cone beam computed tomography when detecting an osteomyelitis/osteonecrosis lesion as well as the lesion's qualitative parameters, extent, and localization. Identification of candidates was performed retrospectively following a search for patients with histologically or clinically confirmed osteomyelitis or osteonecrosis. They were matched with a list of patients whose disease extent and localization had been evaluated using single-photon emission computed tomography and cone beam computed tomography in the context of clinical investigations. Subsequently, two experienced examiners for each imaging technique separately performed de novo readings. Detection rate, localization, extent, and qualitative parameters of a lesion were then compared. Twenty-one patients with mandibular osteomyelitis and osteonecrotic lesions were included. Cone beam computed tomography detected more lesions than single-photon emission computed tomography (25 vs. 23; 100% vs. 92%). Cone beam computed tomography showed significantly greater depth, area, and volume, whereas length and width did not differ statistically between the two groups. Both single-photon emission computed tomography and cone beam computed tomography could sensitively detect osteomyelitis/osteonecrosis lesions. Only single-photon emission computed tomography showed metabolic changes, whereas cone beam computed tomography seemed to display anatomic morphological reactions more accurately. The selection of the most adequate three-dimensional imaging and the correct interpretation of preoperative imaging remains challenging for clinicians. In daily clinical practice, three-dimensional imaging is an important tool for evaluation of osteomyelitis/osteonecrosis lesions. In this context, clinicians should be aware of differences between single-photon emission computed tomography and cone beam computed tomography when detecting and assessing an osteomyelitis/osteonecrosis lesion, especially if a surgical bone resection is planned.

Clinical characteristics and surgical outcome of prolactinoma in patients under 14 years old.

Prolactinoma is one of the most common pituitary tumors, but relatively uncommon in patients under 14 years old. Surgery is the second-line treatment for prolactinoma when patients show resistance or intolerance to medical therapy. There are only a few published series of children who underwent surgery treatment. This study is performed to investigate the clinical manifestation and surgical outcome of pituitary prolactinoma in patients under 14 years old who are resistant or intolerant to medical therapy of dopamine agonist.Thirty-six cases were included in a retrospective review of patients under 14 years old operated for prolactinoma between December 1987 and December 2015. Preoperative radiological and endocrinal evaluation was performed on every patient. All patients received operation with trans-sphenoidal approach.Based on enhanced pituitary magnetic resonance imaging (MRI) taken 2 months after the surgery, total resection was achieved in 16 patients (44.4%) and subtotal resection in 20 (55.6%). Thirty-four cases (94.4%) showed remarkable decrease of prolactin (PRL) level 7 days after surgery, and 16 (44.4%) returned to normal. All patients were followed up for 2 years. Tumor regrowth or recurrence occurred in 5 patients and secondary treatment was applied, including drug treatment in 2 patients, second surgery in 2, and radiotherapy in 1.Trans-sphenoidal pituitary surgery is an effective treatment for prolactinoma in patient under 14 years old. There is no significant difference between the patients under 14 years old and adults for prolactinoma in characteristics and treatment.

The Relationship Between the Pneumatization Patterns of the Frontal Sinus, Crista Galli and Nasal Septum: A Tomography Study.

To provide detailed information about anterior skull base anatomy. In terms of gender and laterality, the drainage pathways and anatomical variations of the frontal sinus, crista galli and nasal septum in 402 patients were evaluated via computed tomography scans. The pneumatization patterns of the frontal sinus were as follows: absent, 3.7%; unilateral, 8%; bilateral, 75.1% and triple, 13.2%. The pneumatized crista galli was identified in 120 (29.8%) patients, and its drainage pathway was observed in 54.1% of patients. The sinus septi nasi was identified in 92 (22.8%) and its drainage pathway was observed in 16.3%. The prevalences of the position types of crista galli regarding the cribriform plate were as follows; type I, 18.3%; type II, 64.9%; type III, 16.8%. Despite meticulous knowledge of anatomy, preoperative radiologic evaluation creates the base for successful treatment of anterior skull base pathologies with safer and effective surgery.

Minimum of 10-year follow-up of V-rod technique in lumbar spondylolysis.

To describe and analyze the use of the V-rod technique described by Gillet to repair spondylolysis in both early and late postoperative periods. Patients submitted to surgical correction of lumbar spondylolysis with a V-rod system were selected upon exclusion of adjacent disk degenerative changes and high-grade spondylolisthesis. A preoperative clinical (ODI and VAS) and radiological evaluation was performed, along with assessments on the early (clinical evaluation-up to 1year) and late (clinical and radiological-at least 10years) postoperative periods. Twenty-two patients were included, 21 with L5 spondylolysis. Fifty percent had grade I spondylolisthesis. A significant decrease in ODI and VAS was observed from pre- to early and late post-op evaluation (all p < 0.05) but not during post-op evaluations. Changes from pre- to postoperative of both ODI and VAS were significantly higher than the minimal clinically important difference. Preoperative ODI and VAS were significantly higher in overweight/obese but similar postoperatively. No additional instability was found in late postoperative X-rays. Three patients needed revision surgery, with a survival rate of 81.8% for Gillet instrumentation at a mean follow-up of 687.7 ± 60.0weeks. Surgical treatment with V-rod system is associated with a significant improvement in ODI and VAS and radiologic stability, with an equal benefit in obese/overweight patients. This study reports for the first time an improvement that is maintained even 10years after the initial intervention, associated with a low rate of failure. These slides can be retrieved under Electronic Supplementary Material.

Approach Selection and Surgical Planning in Posterior Cranial Fossa Meningiomas: How I Do It.

Posterior cranial fossa meningiomas represent approximately 9% of all the intracranial meningiomas. Despite the recent reports of radiation therapy in the management of these tumors, surgical resection continues to be the first line of treatment method aiming the permanent meningioma eradication. The evolution of imaging studies improved the preoperative evaluation of meningiomas providing greater anatomical detail of small structures not previously visualized. Nonetheless, the preoperative radiological evaluation should go beyond the differential diagnosis of a posterior fossa tumor. Anatomo-radiological assessment of meningiomas is discussed in detail. Based on our clinical experience, literature review, and case illustration, we highlight important preoperative anatomo-radiological aspects of posterior fossa meningiomas and their implications in the surgical management of these tumors.

High rate of occult cancer found in prophylactic mastectomy specimens despite thorough presurgical assessment with MRI and ultrasound: findings from the Hereditary Breast and Ovarian Cancer Registration 2016 in Japan

PurposeProphylactic surgery is a preemptive strategy for hereditary breast and ovarian cancer (HBOC). Prophylactic mastectomy (PM) reduces breast cancer risk by > 90%. The aim of our study is to analyze the information of the Japanese pedigrees and to utilize the results for clinical practice.MethodsWe statistically analyzed records of HBOC registrees who had undergone BRCA1/2 genetic testing at seven medical institutions up until 2016. In the cases of PM, we examined breasts with the use of mammography (MMG), ultrasound (US), and magnetic resonance imaging (MRI) before surgery. After PM, the specimens were divided about 1 cm serially and examined in their entirety.ResultsOf 1527 registrees who underwent BRCA testing, 1125 (73.7%) were negative for BRCA1/2 mutation, 297 (19.5%) were positive for BRCA1/2 mutation (BRCA1/2MUT+), and 105 (6.9%) had uncertain results. To decide whether to undergo total mastectomy vs. breast-conserving surgery (BCS), 370 registrees underwent presurgical genetic testing. During the follow-up period, four new-onset breast cancers were found among the 55 non-affected BRCA carriers. Among the 73 BRCA1/2MUT+ carriers who underwent BCS, 3 were found to have ipsilateral breast cancer. Of 189 BRCA1/2MUT+ carriers with unilateral breast cancer, 8 were found to have contralateral breast cancer. Of 53 PM specimens, 6 (11.3%) were found to have occult breast cancer despite using MMG, US, and MRI.ConclusionsOur report showed a relatively higher incidence rate of occult cancer at 11.3% in PM specimens despite thorough pre-operative radiological evaluations, which included a breast MRI. Considering the occult cancer rates and the various pathological methods of our study and published studies, we propose the necessity of a histopathological protocol.

Modified nasal floor and inferior meatus flap for septal perforation repair. Extension and limits.

The nasal floor and inferior meatus (NFIM) flap represents an available option for the reconstruction of a septal perforation (SP). This study explores the feasibility of repairing SPs using a modified simple and extended (including inferior turbinate) NFIM flap. An anatomic study was achieved in fresh frozen cadaveric specimens to measure the area and lengths of NFIM flap. The repair of SP with simple and extended NIFM flaps was performed in some of these cadaveric specimens. Preoperative radiological evaluation of CT scans allowed studying the reconstruction limits of the simple or extended NFIM flap. A cohort of patients with SP who underwent reconstruction with an NFIM flap was also included. Complete SP repair with NFIM was achieved in all specimens (n=10). In 38 fresh cadaveric specimens, coronal and sagittal lengths and area of simple NFIM flaps were smaller than in extended NFIM flaps. The radiological analysis of 75 CT scans revealed that the septal height could be reconstructed with a simple and extended NFIM flap. Complete SP repair wasachieved in 5 patients (4 male, mean age 57.4 years) using modified NFIM flaps. The simple or expanded NFIM flap represents a feasible option to repair small or medium-sized perforations located at the lower 1/3 or 3/4 of the nasal septum.

Diagnostic performance of CT, MRI, and their combined use for the assessment of the direct cranial or intracranial extension of malignant head and neck tumors.

Preoperative radiological evaluation of the cranial or intracranial extension of malignant head and neck tumors is critical in the planning of curative surgery. To assess the diagnostic accuracy of computed tomography (CT) combined with magnetic resonance imaging (MRI), compared to CT or MRI alone in diagnosing the direct cranial or intracranial extension of malignant head and neck tumors, using histopathologic results as the reference standard. CT and MRI images in 41 patients with malignant head and neck tumors abutting the skull were retrospectively reviewed. The images were evaluated for the presence or absence of skull invasion (erosion/destruction of the skull), dural invasion (nodular dural enhancement), and brain invasion (enhancing brain lesion with or without brain swelling/edema). The results of the CT alone, MRI alone, and CT combined with MRI were compared with the histopathologic findings. Of the 41 patients studied, ten had no invasion, eight had skull invasion, 17 had dural invasion, and six had brain invasion by tumor. The sensitivity/specificity/accuracy of CT alone, MRI alone, and CT combined with MRI for diagnosing intracranial extension were 78.0%/100%/94.5%, 85.4%/80.5%/93.9%, and 95.1%/100%/98.8%, respectively. The sensitivity of CT combined with MRI was significantly higher than those of CT alone ( P = 0.0156) and MRI alone ( P = 0.0313). CT combined with MRI is a more sensitive tool for the diagnosis of the direct cranial or intracranial extension of malignant head and neck tumors than CT alone and MRI alone.

MRI as an Alternative to Second Look Mastoid Surgery

The main goal of surgery of cholesteatoma is eradication of the disease and revision surgery is indicated when a dry and safe ear has not been achieved. Residual cholesteatoma usually occurs at the sites that are difficult to reach with an operating microscope, such as posterior tympanum and anterior epitympanic recess. Computed tomography can be performed to delineate the extent of disease. High-resolution computed tomography scanning is important for planning for surgery and is indicated for all revision mastoid operations. Magnetic resonance imaging is superior to computed tomography in tissue characterization for diagnosis of recurrent cholesteatoma. To evaluate the cases of recurrent cholesteatoma comparing the intraoperative surgical findings with the preoperative MRI radiological findings and if the preoperative MRI can replace the second look surgery for cholesteatoma. This study was applied on 60 patients that have a recurrent cholesteatoma after previous mastoid surgery. A preoperative radiological evaluation was done by Magnetic resonance, surgical management was done by canal wall up or canal wall down mastoidectomy to exclude residual disease. Then, radiological, and surgical findings correlation was done. Diffusion-weighted MRI successfully detected 42 cases out of the 45 cases of surgically proved cholesteatoma, it has accuracy 95%, sensitivity 93.33%, specificity 100%, PPV 100% and NPV 83.33%. MRI is better than CT in tissue characterization for diagnosis of recurrent cholesteatoma, and can replace the unnecessary second look surgery of cholesteatoma.

Surgeon Oriented Preoperative Radiologic Evaluation in Cochlear Implantation - Our experience with a Proposed Checklist.

Introduction Preoperative temporal bone imaging studies have been routinely performed prior to cochlear implantation. Radiologists need to report these examinations with special focus on the surgeon's expectations. Objectives To provide a basic structured format, in the form of a checklist, for reporting preoperative computed tomography (CT) and to its clinical impact on operative findings. Methods The preoperative temporal bone CT scans of 47 patients were analyzed and reported according to the proposed checklist. Intraoperative assessment of mastoidectomy, posterior tympanotomy and round window access was done by the surgeon in a blinded fashion and were correlated with the radiological findings to assess its significance. Results The proposed radiological checklist was reliable in assessing operative difficulty during cochlear implantation. Contracted mastoid and lower tegmen position were associated with a greater difficulty of the cortical mastoidectomy. Presence of an air cell around the facial nerve (FN) was predictive of easier facial recess access exposure. Facial nerve location and posterior external auditory canal (EAC) wall inclination were predictive of difficult round window (RW) accessibility. Conclusion Certain parameters on the preoperative temporal bone CT scan may be useful in predicting potential difficulties encountered during the key steps involved in cochlear implant surgery.

PREOPERATIVE RADIOLOGIC EVALUATION OF BRONCHO-PLEURAL FISTULA AS PREPARATION FOR TRANSSTERNAL MAIN BRONCHIAL STUMP OCCLUSION

Objective:retrospective assessment of preoperative radiologic evaluation of patients with chronic pleural empyema and bronchopleural fistula after pneumonectomy and its influence on the choice of transsternal main bronchial stump occlusion as definitive surgical treatment.Methods.From April 2005 to December 2016 in A.V. Vishn evsky Institute of Surgery 25 patients with chronic pleural empyema (&gt;12 weeks from the onset of the disease) and bronchopleural fistula (BPF) after pneumonectomy were treated. The main methods of preoperative diagnosis were fibrobronchoscopy and multispiral computed tomography. The results of treatment of BPF after pneumonectomy by transsternal bronchial occlusion as a method of choice were retrospectively analyzed.Results.Depending on the length of the bronchial stump and the diameter of the BPF, evaluated with CT, patients were divided into two groups. In 9 (36%) patients with bronchial stump length ≥20 mm and BPF diameter ≥3mm performed transsternal bronchial closure. In 16 patients (64%) with short (less than 20 mm) bronchial stump BPF was covered with muscle flap (87.5%) or omental flap transposition (12.5%) was done. Perioperative mortality rate was 2 (8 %) of 25 (95% CI: 2.2–24.9) cases due to ARDS and severe sepsis in muscleflap group. Recurrence rate was 2 (12.5%) of 16 (95% CI: 3.5–36) patients in control group vs no recurrence rate in basic group according to 18–110 months follow up.Conclusion. Radiologic methods are the gold standard in the diagnosis of pleural empyema with BPF. A differential approach based on the assessment of risk factors (the etiology of empyema, length of the stump of the main bronchus, diameter of bronchial fistula and initial state of residual pleural cavity) makes it possible to reduce morbidity and mortality in patients with BPF.

Decision-making for complex scapula and ipsilateral clavicle fractures: a review

Complex scapulawith ipsilateral clavicle fracuresremains a challange andtreatment recommendations are still missing. This review provides an overview of the evolution of the definition, classification and treatment strategies for complex scapula and ipsilateral clavicle fractures. As with other rare conditions, consensus has not been reached on the most suitable management strategies to treat these patients. The aim of this review is twofold: to compile and summarize the currently available literature on this topic, and to recommend treatment approaches. Included in the review are the following topics: biomechanics of scapula and ipsilateral clavicle fractures, preoperative radiological evaluation, surgical treatment of the clavicle only, surgical treatment of both the clavicle and scapula, and nonsurgical treatment options. A decision-making algorithm is proposed for different treatment strategies based on pre-operative parameters, and an example of a case treated our institution is presented to illustrate use of the algorithm. The role ofinstabilityin complex scapula with ipsilateral clavicle fractures remains unclear. The question of stability is preoperatively less relevant than the question of whether the dislocated fragments leadto compromised shoulder function.

Abstract PD1-09: High incidence rate of occult cancer in risk reducing mastectomy specimens despite thorough assessment with breast MRI and ultrasound-findings from the hereditary breast and ovarian cancer registration 2016 in Japan

Abstract Introduction:One of the preemptive strategies for Hereditary Breast and Ovarian Cancer (HBOC) is prophylactic surgery. Data for risk reducing mastectomy (RRM) clearly showed a risk reduction of more than 90% for breast cancer. Method: We report here the statistical results of the HBOC registration up to 2016. The subjects of this study were those who underwent BRCA1/2 genetic testing during the study period, at 7 medical institutions. Results: A total of 1527 probands underwent BRCA testing; 1125 cases (73.7%) were negative for BRCA1/2 mutation, and 297 cases (19.5%) were positive, while 105 cases (6.9%) had uncertain results. Among the 297 cases with positive results, 157 cases (10.3%) were positive for BRCA1, 139 cases (9.1%) for BRCA2, and 1 case (0.1%) was positive for both.The mean age at breast cancer diagnosis was 41.7 years in BRCA1/2 mutation positive and 45.8 years in negative cases. In comparison to the National Registration for Breast Cancer Incidence 2011 in Japan (n=72,472), breast cancer with BRCA mutations occurred at a younger age. Among 359 cases of triple negative breast cancer, 101 cases (28.3%) were BRCA1 mutation positive while 18 cases (5.0%) were BRCA2 mutation positive. Three hundred seventy cases underwent genetic testing prior to surgery, as a deciding factor for the surgical procedure. Among BRCA mutation positive cases, 58 cases (87.9%) chose to undergo total mastectomy, and 8 cases (12.1%) chose breast conserving surgery (BCS); on the other hand, 141 cases (46.4%) of BRCA mutation negative cases chose total mastectomy and 158 cases (52.0%) chose BCS. Four cases of new onset breast cancers were observed among the 55 cases of previvors (mean observation period: 2.5 years; incidence rate: 2.9%/Y). Among the 73 BRCA1/2 mutation positive women who underwent BCS, 3 ipsilateral breast cancer cases were observed (mean observation period: 3.5 years; incidence rate: 1.2%/Y), while 2 cases were noted among 477 cases of BRCA1/2 mutation negative cases (mean observation period: 2.2 years; incidence rate: 0.2%/Y). Of 189 BRCA1/2 mutation positive cases with unilateral breast cancer, 8 contralateral breast cancer cases were noted (mean observation period: 3.0 years; incidence rate: 1.4%/Y), while 4 cases of contralateral breast cancer were observed among 892 cases of BRCA1/2 mutation negative cases (mean observation period: 2.2 years; incidence rate: 0.2%/Y). Fifty-one patients had undergone RRM.Six cases (11.8%) of occult breast cancer were noted in the RRM specimens, among which 2 were BRCA1 positive cases and 4 were BRCA2 positive cases. All of these six cases had undergone extensive imaging work-up prior to surgery by using mammography, ultrasound and breast MRI. Conclusions: The incidence rate of occult cancer after risk-reducing mastectomy was reported to be about 5% in the high-risk population. Our report showed a relatively higher incidence rate of occult cancer at 11.8% among BRCA mutation positive cases, despite thorough pre-operative radiological evaluations, which included a breast MRI. These results suggest the limitations in the use of MRI for the surveillance of patients with BRCA mutations. Citation Format: Yamauchi H, Okawa M, Yokoyama S, Nakamura S, Arai M. High incidence rate of occult cancer in risk reducing mastectomy specimens despite thorough assessment with breast MRI and ultrasound-findings from the hereditary breast and ovarian cancer registration 2016 in Japan [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD1-09.

Adenomatous hyperplasia of the ampulla of Vater

Background: Adenomyomatous hyperplasia of Vaterian system is rare with less than 20 cases reported in the English language literature. Preoperative endoscopic and radiological evaluations findings are of a mass lesion and the typical concern is for malignancy. Diagnosis requires histological examination.