Previous Excision Research Articles

Primary Cutaneous Actinomycosis along with the Surgical Scar on the Hand.

Primary cutaneous actinomycosis is a rare clinical form with variable presentation. The tumoral presentation of actinomycosis as pseudocarcinomatous or sarcomatous masses is completely rare. The management of cutaneous actinomycosis needs proper antibiotic treatment and surgical resection would not be adequate alone. Herein, we report a case of primary cutaneous actinomycosis on the dorsal surface of the hand as draining and infiltrated lesions along with the scar of previous tumor excision that had not received proper antibiotics after the surgery.

The Burden of Unplanned Excision of Soft Tissue Tumours in Developing Countries: A 10-Years’ Experience at a Regional Cancer Centre

Background: Local recurrence in soft tissue sarcomas is the major onus of the disease which could result in nonfunctioning extremities. The local recurrence of soft tissue tumours is the major morbidity and cause for this is the unplanned surgery at inexperienced peripheral centers. We noticed that a major proportion approximate one fourth patient with soft tissue tumours presented in outdoor, were with residual or recurrent lesion. Aim: The aim was to examine the clinical and pathological profile of soft tissue tumours that had undergone unplanned excision in aspect to the natural event of recurrence in respect to surgery which has been performed. Materials and methods: In total, 126 patients who had undergone prior surgery of the tumour without oncological planning presented to our institute with residual or recurrent soft tissue tumours between January 2005 to December 2014 were analyzed in a retrospective study. Results: There were a total of 126 patients analyzed. The mean age was 44.3 ± 16.9 years. Average duration from previous unplanned excision to presentation was 5.3 months (1-57 months). 29 patients were presented immediately after the first surgery with clinical residual lesion with a diagnosis of soft tissue sarcoma, while 97 patients presented after apparent local recurrence. Most of the tumours were almost evenly distributed among low and high grade (40.5% vs. 59.5%), superficial and deep seated (48.4% vs. 51.6%), and <5 cm in size (62.9%). 99 (78.6%) patients presented within 24 months after unplanned excision. 22 (17.4%) patients were presented with distant metastasis also with local recurrence. Conclusion: The appropriate planning regarding as diagnosis as treatment purpose for the soft tissue sarcoma without assuming the soft tissue mass as benign lesion. It helps to reduce the morbidity due to recurrence after inadequate surgical excision.

Repair of 50-75% full-thickness lower eyelid defects: Lateral stabilization as a guiding principle.

Introduction:Repair of large defects of the lower eyelid can be difficult. A common procedure performed to address these defects is a Hughes flap. This procedure has a number of disadvantages: The eye is closed postoperatively, a second stage is required, and the edge of the flap is often erythematous. The purpose of this paper is to describe a one-stage procedure for the repair of large full-thickness defects of the lower lid as an alternative to a Hughes flap.Materials and Methods:This is a retrospective study of patients who underwent the described procedure. The procedure employs lateral stabilization of the posterior lamella with a periosteal strip, medial transposition of the lateral posterior lamella for central and medial defects, and a myocutaneous advancement flap to stabilize the anterior lamella.Results:A total of 38 patients underwent the procedure to reconstruct full-thickness defects of the lower lid ranging from 50% to 75%. All patients underwent previous Mohs excision of a skin cancer. The average follow-up was 5.6 months. Eleven patients (29%) had postoperative sequelae, but only two patients (5%) required additional treatment.Conclusion:Lateral stabilization with a periosteal strip and myocutaneous advancement flap is an excellent one-step procedure that avoids many of the complications seen with the Hughes procedure and is comparable to other techniques used for the reconstruction of subtotal, full-thickness lower lid defects.

Feasibility and Safety of Ultrasound-Guided Vacuum-Assisted Breast Biopsy System for Intraductal Papilloma

Purpose: We aimed to evaluate the feasibility and safety of ultrasound-guided vacuum-assisted breast biopsy system for the treatment of intraductal papilloma (IDP). A vacuum-assisted breast biopsy system mammotome® was recently introduced for simultaneous biopsy and excision of benign breast masses. Mammotome excision has the advantages of safety and less scar formation compared to open biopsy. Wide excision is a standard treatment for IDP of the breast. Methods: We retrospectively reviewed the clinical data by using the electric medical records of 752 cases of breast masses that were treated via Mammotome excision performed by a single surgeon between January 2007 and December 2012. Among these patients, 26 patients were diagnosed with benign IDP as indicated in the final pathologic reports. Results: The median follow-up period was 56.2 months (range, 29–92 months). Two patients were diagnosed with another IDP during the follow-up period. However, no recurrence was detected at the previous excision site, but new primary lesions were confirmed at another quadrant. Conclusion: We suggest that ultrasound-guided vacuum-assisted breast biopsy system may be feasible and safe for the treatment of IDP. Keywords: Biopsy; Breast; Excision; Intraductal papilloma

Prophylactic removal and microbiological evaluation of calcified plaques after pterygium surgery.

The aim of this study was to investigate microbiological characteristics of prophylactically removed calcified plaques developed after pterygium excision, and to evaluate risk factors for the growth of microorganisms. Only exposed calcified plaques developed at the same site of previous pterygium excision were prospectively removed in 15 eyes of 14 patients. Plaques were completely removed, divided into small pieces and evaluated for microbiological identification. Underlying scleral defects were reconstructed using a conjunctival autograft, amniotic membranes and scleral patch grafts according to the size and depth of the defects. Based on the results of microbiologic cultures, eyes were divided into two groups and risk factors for microbial growth were analyzed. At surgery, the mean age of the patients was 71.2 ± 5.8 years and 71.4 % were females. The mean time interval between pterygium excision and calcified plaque removal was 19.3 ± 13.8 years. Six of 15 (40 %) removed plaques showed bacterial growth, and Stenotrophomonas maltophilia was the most frequently isolated microorganism. The size of calcified plaques was the only risk factor for culture-positive results (p = 0.045). Underlying scleral defects were successfully repaired without any serious complication. Microorganisms can be isolated from calcified plaques developed at the site of previous pterygium excision, and the size of plaques is the only risk factor for culture-positive results. To remove potential source of infection, prophylactic removal of calcified plaques and scleral surface reconstruction should be considered, especially when the plaques are exposed and large.

Block‐flow noise power estimation algorithm for pulsed interference detection of GNSS receivers

The noise power estimation for pulsed interference detection in global navigation satellite system (GNSS) receivers is considered. Previous effective consecutive mean excision (CME) related algorithms in this area work in an inter-block iterative fashion and the convergent process is usually quite time-consuming and needs a large storage space. A block-flow manner based on the backward CME (BCME) algorithm to overcome these problems is proposed. Numerical results show that the method decreases the computation and storage requirements of BCME, and possesses closer convergence properties.

An unusual case of life-threatening airway compromise complicating a neck dissection

Sir, The potential complications associated with neck dissection classically include damage to important neurovascular structures within the dissection parameters. However, there are no documented cases within the literature that describe severe delayed airway compromise as a result of unilateral or bilateral neck swelling in the perioperative period. A degree of post-operative swelling is to be expected, but delayed airway compromise requiring intubation and intensive care unit support following neck dissection is uncommon. We report an unusual case of severe unilateral neck swelling developing secondary to an elective neck dissection together with a discussion of current diagnostic and management strategies. A 64-year-old male underwent a left modified radical neck dissection (levels I–V) following previous excision of a 2.4 mm Breslow thickness melanoma on the left shoulder and subsequent cytology-confirmed metastatic lymphadenopathy in the left posterior triangle. Pre-operative intravenous augmentin was administered, and three drains were placed at the conclusion of surgery. Following an uncomplicated recovery, all drains were removed and the patient was discharged 6 days later. He subsequently presented 48 h post-discharge with rapid onset swelling of the left side of the neck. A CT scan suggested a collection in the submandibular region causing moderate airway compromise and midline airway shift (Figs. 1a, b and 2a, b). Re-exploration of the neck dissection identified marked swelling of the anterior belly of the digastric and myoglossus muscles, but no collections or haematoma. Microbiology swabs of the neck sent from theatre confirmed the presence of Staphylococcus aureus in the wound. Intravenous tazocin and clindamycin were commenced, and the patient returned to intensive care intubated. The patient was extubated after 36 h following clinical improvement and discharged the following day with no further episodes of neck swelling or long-term sequelae. Ludwig’s angina was the initial diagnosis in this patient, but given that the infection was unilateral, it did not fit the classical diagnostic criteria of bilateral neck swelling. Ludwig’s angina is a life-threatening cellulitis, usually originating in the submandibular space. This condition typically occurs secondary to odontogenic infections [1], with the most common pathogens identified as Streptococcus viridans, S. aureus and Staphylococcus epidermidis, and group B streptococcus [1, 2]. Other recognised causes include parapharangeal abscesses, mandibular fractures, oral piercings, submandibular gland sialadenitis and oral malignancy [1]. Those suffering from dental caries and systemic illnesses such as diabetes mellitus, malnutrition, alcoholism and immunosuppression are also at risk [2, 3]. Ludwig’s angina often begins as a mild infection which rapidly progresses to bilateral swelling of the neck and floor of the mouth with associated trismus, tongue elevation, and stridor, ultimately leading to airway compromise and asphyxia [1–4]. The presence of cellulitis helps to differentiate this condition from others such as haematoma [5]. Without treatment, Ludwig’s angina carries a high mortality of 50 %, although this figure is markedly reduced to 10 % by antibiotics and supportive treatment [1, 2, 6, 7]. * Philip Rubin Philip.Rubin@cddft.nhs.uk

High-grade myxoinflammatory fibroblastic sarcoma: a report of 23 cases

We describe 23 cases of high-grade myxoinflammatory fibroblastic sarcoma (MIFS). The patients were 15 women and 8 men, with the age ranging at the time of diagnosis from 39 to 93 years (mean, 64.3 years; median, 66 years). Follow-up was available for 18 patients, of whom 9 developed metastatic disease; 7 of these died. Most tumors showed a predilection for the soft tissues of the extremities, with 14 cases involving the lower limb and 5 the upper extremity. However, in both sites, the acral parts were affected in only 1 case each. Of the 4 remaining tumors, 2 were found in axilla, 1 was found in sacral area, and 1 developed in the scar on the breast, 14 years after previous excision of a mammary carcinoma and subsequent local irradiation. The tumor size ranged from 1.3 cm to as much as 30 cm in the largest dimension with a mean size of 8.3 cm. Histologically, the tumors were characterized by occurrence of 3 types of characteristic cells, including (1) lipoblast-like cells with an ample, distended, mucin-filled cytoplasm compartmentalized by a variable number of intracytoplasmic septa, thus remotely resembling soccer balls; (2) large, polygonal, bizarre ganglion-like cells similar to those seen in the Hodgkin disease, also called Reed-Sternberg-like cells. Within an ample, deeply eosinophilic cytoplasm, there was an oval nucleus with vesicular chromatin and a large, inclusion-like nucleolus. Binucleated, multinucleated, or more pleomorphic forms of these cells were also present; (3) cells with emperipolesis of variable sizes, ranging from very inconspicuous neoplastic cells containing only one to a few engulfed cells to conspicuous large ones having many inflammatory cells, usually polymorphonuclear leukocytes admixed with various numbers of some lymphoid cells, within the cytoplasm. Quite often, we found elements that combined the histologic features of all the above 3 characteristic tumor cell types. In 2 tumors, we found an additional undifferentiated spindle cell sarcoma component, whereas in another tumor, a chondrosarcomatous moiety was evident. For comparison, we studied 10 cases of pleomorphic hyalinizing angiectatic tumor (PHAT) of soft tissues. Based on the identification of morphological changes typical for MIFS within most of the cases of PHAT, we suggest that most cases of PHAT represent examples of MIFS merely having hyaline ectatic vessels.

Meniscal and Articular Cartilage Predictors of Clinical Outcome following Revision ACL Reconstruction

Objectives:Revision ACL reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. The reasons why remain unknown. The purpose of this study was to determine if both the prevalence and/or degree of meniscal and chondral damage noted at the time of ACL revision reconstruction predicts activity level, sports function, and OA symptoms at two year follow-up.Methods:Revision ACL reconstruction patients were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 2 years, and asked to complete the identical set of outcome instruments. Regression analysis was used to control for age, gender, BMI, smoking status, activity level, baseline outcome scores, revision number, time since last ACLR, previous and current meniscal and articular cartilage pathology, in order to assess the meniscal and AC pathology risk factors for clinical outcomes 2 years after revision ACL reconstruction.Results:1205 patients met the inclusion criteria and were successfully enrolled. 697 (58%) were males, with a median cohort age of 26 years. The median time since their last ACL reconstruction was 3.4 years. Surgeons noted previous pathology in the medial meniscus (39%), lateral meniscus (20%), and articular surfaces (12%) at the time of revision surgery. Surgeons reported current pathology in the medial meniscus (45%), lateral meniscus (37%), MFC (43%), LFC (29%), MTP (11%), LTP (17%), patella (30%), and trochlea (20%). At 2 years, follow-up was obtained on 82% (989/1205). Previous meniscal pathology (both medial and lateral), as well as current AC pathology (in the MFC, LFC, MTP, LTP, and trochlea) were found to be significant drivers of poorer outcomes at 2 years (Table 1). The most consistent cartilage-related factors driving outcome in revision patients were previous lateral meniscus pathology and current trochlea AC pathology. Having a previous excision on the lateral meniscus resulted in significantly poorer outcomes on the IKDC (odds ratio=1.69; 95% CI=1.16-2.44; p=0.005), all KOOS subscales (OR range=1.54-2.08; 95% CI=1.04-3.03; p<0.029), and all WOMAC subscales (OR=1.56; 95% CI=1.06-2.27; p=0.02). Having a current Grade 3-4 AC chondrosis of the trochlea resulted in significantly poorer outcomes in the IKDC (OR=1.89; 95% CI=1.25-2.94; p-0.003), 4 of 5 KOOS subscales (OR range = 1.64-2.70; 95% CI=1.09-4.17; p<0.02), and 2 of 3 WOMAC subscales (OR range = 1.61-2.70; 95% CI=1.04-4.17; p<0.03). Lower baseline outcome scores, lower baseline activity level, and shorter time since the patient’s last ACL reconstruction all significantly increased the odds of reporting poorer clinical outcomes at 2 years. Meniscal and AC pathology was not found to be a significant risk factor for 2 year activity levels. Interestingly, previous AC pathology and current meniscal pathology were not found to be significant risk factors for 2 year outcomes in this revision cohort.Conclusion:Having a previous meniscal excision, as well as grade 3-4 chondral damage noted at the time of ACL revision reconstruction results in decreased sports outcome scores and worse WOMAC scores at two years following revision surgery. However, incidence of meniscal and AC pathology was not found to be a predictor of a patient’s activity level at 2 years.

V33 Robot assisted perineal radical prostatectomy in the setting of previous AP excision of rectum

V33 Robot assisted perineal radical prostatectomy in the setting of previous AP excision of rectum

Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques.

Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection. The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps. This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries. This study was conducted at a single institution. All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp. Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured. Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days. This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up. Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.

Experience of scleritis and episcleritis at a tertiary center in Southern Taiwan

PurposeThe purpose of this study was to review the clinical experiences of scleritis and episcleritis in Southern Taiwanese people during a 7-year period. MethodsThe charts of 89 patients (representing 101 eyes) who had visited our clinic from January 2003 to July 2010 were retrospectively reviewed. They were diagnosed as having episcleritis or scleritis. The medical charts, slit lamp photographs, and laboratory data were reviewed. Age, gender, laterality, previous surgery history, systemic diseases, follow-up duration, and ocular complications were collected. The patients were classified as having clinically suspected noninfectious scleritis (CSNIS), clinically suspected infectious scleritis (CSIS), and episcleritis for analysis. ResultsIn the series of 89 patients (i.e., 101 eyes), 31 (34.8%; 32 eyes) patients had scleritis and 58 (65.2%; 69 eyes) patients had episcleritis. Episcleritis and scleritis occurred slightly more frequently in women than in men. In the 31 patients (32 eyes) diagnosed with scleritis, 12 (38.7%) patients had CSIS and 19 (61.3%) patients had CSNIS. Patients with scleritis were older than patients with episcleritis (p < 0.001). Previous pterygium excision was associated with CSIS and necrotizing scleritis. ConclusionScleritis occurred in a more elderly population. It was more frequently associated with ocular complications, compared to episcleritis. Both CSNIS and CSIS were associated with a history of pterygium excisional surgery. Our series of patients had a high occurrence of necrotizing scleritis. All cases of necrotizing scleritis were associated with a history of previous ocular surgery.

Medial Crease Formation in Unfavorable Subbrow Excision: Medial Crease in Subbrow Excision

Background Various surgical techniques have been developed to address senile upper eyelids. Upper blepharoplasty has limited efficacy in natural periorbital rejuvenation for severe lateral hooding of the upper eyelids, as well as often producing a 'surprised look'. Subbrow excision is a popular method in East Asia for the correction of eyelid drooping, especially on the lateral side as periorbital rejuvenation. However, medial up- per eyelid skin redundancy often tends to be undercorrected. Here, we present a few cases of revisional blepharoplasty, especially for medial crease formation, to improve aesthetic results. Methods Five patients, for a total of 10 eyelids, who underwent revisional blepharo- plasty from January 2011 to January 2015 after a previous subbrow excision, were in- cluded. Patients were dissatisfied with uncorrected excessive skin on the medial part of the upper eyelid after a previous subbrow excision; thus, they underwent revisional blepharoplasty for medial crease formation. Results During the follow-up period, patients were aesthetically satisfied with the post- operative results. No patients suffered from any complications during the follow-up period.

Positive endocervical margins at conization: repeat conization or colposcopic follow-up? A retrospective study.

BackgroundThe presence of residual cervical lesions was evaluated in patients submitted to repeat conization due to a finding of positive endocervical margins in a previous loop electrosurgical excision procedure (LEEP) specimen. In addition, the correlation between the presence of a residual lesion and risk factors for cervical cancer, and the use of repeat conization as first-choice treatment were analyzed.MethodsThis retrospective study included 44 patients submitted to repeat cervical conization or total hysterectomy following a finding of affected endocervical margins in LEEP specimens. The risk factors analyzed in relation to the presence of residual lesions were age, smoking, cone depth, glandular involvement and the histopathology findings of cervical intraepithelial neoplasia (CIN) 1, CIN 2 or CIN 3/carcinoma in situ. The Chi-square test and the Mann-Whitney t-test were used, with significance defined at P < 0.05.ResultsResidual lesions were found in 23/44 patients (52.3%), with 3/23 cases (13.0%) being compatible with invasive squamous cell carcinoma. Of the 23 patients, six (26.1%) were submitted to total hysterectomy, with one case being compatible with a moderately differentiated invasive squamous cell carcinoma. Two patients with a histopathology finding of CIN 3/carcinoma in situ in the previous LEEP specimen were diagnosed with invasive squamous cell carcinoma in the repeat conization specimen. Residual lesions were not significantly associated with the risk factors evaluated.ConclusionsIn view of the high frequency of residual disease found when positive endocervical margins were found in LEEP specimens, the indication for repeat cervical conization rather than colposcopic follow-up is viable and justified. Indeed, since the presence of a residual lesion and its progression in the cervical canal are more difficult to screen and control, patients unable to comply with regular colposcopic follow-up could benefit from repeat conization when trying to avoid a potentially negative outcome.

Autologous advanced tenon grafting combined with conjunctival flap in scleromalacia after pterygium excision.

Purpose. To evaluate the efficacy of autologous tenon grafting combined with conjunctival flap as a treatment for scleromalacia or scleral thinning after pterygium excision without any additional donor graft tissue. Methods. Twenty-six cases underwent autologous advanced tenon grafting combined with sliding or rotating conjunctival flap for scleromalacia after pterygium surgery ranging from 2 years to 30 years. The extent of scleral defect measured from 2.0 mm to 6.8 mm in diameter. The cosmetic outcome was defined as complete resolution of scleromalacia or completely conjunctival reepithelialization and firm adhesion between subtenon and scleral tissue over scleral thinning without significant complications. Results. All cases achieved the covering of conjunctival and tenon or subtenon tissue over scleromalacia or scleral thinning with this procedure. Preoperative pain, inflammation, and choroidal exposure disappeared after surgery. Immediate postoperative complications, such as large wound dehiscence or reopening of the scleral wound, did not occur in any of the patients. There were no significant clinical complications during the mean postoperative follow-up period of 14.17 months in all cases. Conclusions. We obtained excellent outcome with fewer complications after autologous advanced tenon graft and conjunctival flap, without an additional donor graft, in scleromalacia or scleral thinning caused by previous pterygium excision.

24. Recurrent chordoma with rhabdoid and chondroid differentiation

Background Chordoma is a rare primary malignant bone tumour derived from remnants of the notochord, accounting for approximately 1–5% of all malignant bone tumours of adulthood affecting males more commonly. The majority of chordomas occur in the axial skeleton with rare extra axial examples reported. Histologically chordomas exhibit low grade features however clinically they are locally aggressive, recur, and metastasise in a significant proportion. Chordomas are classified into conventional, chordoid with similar biological behaviour as the conventional and dedifferentiated which is exceptionally rare and is composed of a high grade sarcoma in a background of conventional chordoma. It also shows poor response to systemic therapy and are resistant to conventional radiotherapy. The treatment of election is excision with wide margins combined with heavy particle or stereotactic photon radiation. Aim We present a case of recurrent chordoma and discus morphological changes in the context of multiple recurrences. Results A 76 year old man with conventional chordoma of the sacrum initially treated with excision and radiotherapy developed multiple recurrences at margins of previous radiotherapy field. Excision of the recurrence and adjuvant IMRT following failed brachytherapy was the elected treatment. In contrast to the presence of typical histological features of conventional chordoma in the previous excision the recurrent chordoma showed rhabdoid differentiation. Several months posterior to treatment he presented with history of progressive bilateral sciatic pain, constipation and diarrhoea. The latest recurrence in the right gluteus muscle showed a chordoma with prominent rhabdoid and chordoid differentiation with prominent nuclear atypia, vascular invasion and positive margins. However there were still no features of dedifferentiation.

Hysterectomy for Abnormal Cervical Smear When Local Excision Is Not Possible

To review the outcomes of those women who underwent hysterectomy because of an abnormal cervical smear where local excision was considered technically not possible. A retrospective chart review was performed for all women who had hysterectomy at a university-affiliated hospital, carried out during the period between January 2000 and June 2012, because of cervical neoplasia. Fifty-six women were identified. The mean (standard deviation [SD]) age of the women at the time of hysterectomy was 61.4 (8.2) years. Two women (3.6%) had cervical carcinoma, and adjuvant treatment was required in both cases. Being postmenopausal and older than 50 years and having a history of previous local excisional procedure were associated with a higher risk of high-grade cervical intraepithelial neoplasia found during hysterectomy (p > .005). During a mean (SD) follow-up of 42.3 (30.8) months after hysterectomy, 35.7% of women had persistent cytologic abnormality after hysterectomy, with 19.6% having subsequent histologically proven vaginal intraepithelial neoplasia (VAIN). Women's age, route of hysterectomy, previous local excision, degree of cytologic abnormality before hysterectomy, presence of VAIN before hysterectomy, and final histology of the hysterectomy specimen could not predict subsequent VAIN after hysterectomy. Hysterectomy seems to be an appropriate option in management, but further surgery or adjuvant therapy may be needed. Women should also be aware of the possibilities of persistent cytologic abnormalities including VAIN, but unfortunately, no predictive factor for its occurrence can be identified.

Predictive value of volume of cervical tissue removed during LLETZ on subsequent preterm delivery: a cohort study

ObjectiveTo evaluate the impact of volume of tissue removed during large loop excision of transformation zone on subsequent preterm birth rates. Study designA retrospective cohort study was carried out in a single, large tertiary referral unit in UK. A total of 556 women who delivered between January 2008 and December 2011 following a previous large loop excision of transformation zone procedure or punch biopsy were identified from the maternity and colposcopy databases. Demographic data, gestational age at delivery, birthweight, neonatal outcome and dimensions of excised cervical specimen were collected. Pregnancy outcomes for women who had a previous loop excision were compared to a matched control group who had undergone punch biopsies only. ResultsThere was a significant increase in preterm birth rate in the large loop excision group compared to the control group (9.0% vs. 3.6%, respectively, RR 2.5, 95% CI 1.224–5.107). Women who had undergone at least one previous loop excision had more than a threefold increased risk of spontaneous preterm birth compared with their matched controls. However, no relationship between volume or depth of cervical tissue excised and subsequent gestation at delivery could be demonstrated. ConclusionsWhilst LLETZ is associated with an increased rate of preterm birth, the volume of tissue removed does not appear to influence the subsequent gestational age at delivery. This should reassure clinicians who should continue to perform LLETZ with adequate tissue margins to ensure complete resection of disease.

Residual and recurrent gradients after septal myectomy for hypertrophic cardiomyopathy—mechanisms of obstruction and outcomes of reoperation

The aims of the present study were to identify the mechanisms of residual or recurrent left ventricular outflow tract obstruction in patients undergoing repeat septal myectomy for hypertrophic cardiomyopathy and to assess the early and late results of reoperation. From January 1980 to June 2012, we performed 52 repeat myectomies in 51 patients. We reviewed the medical records and preoperative transthoracic echocardiograms to evaluate the adequacy of the previous resection and mechanism of left ventricular outflow tract obstruction. The complications of previous and repeat myectomy, New York Heart Association class, and survival were analyzed. The mean interval from previous myectomy to reoperation was 43 ± 51 months. In 6 patients (12%) residual or recurrent gradients were caused by isolated midventricular obstruction. In the remaining 46 operations, the mechanism of residual or recurrent gradients was identified as systolic anterior motion of mitral valve-related subaortic obstruction caused by inadequate length of previous subaortic septal excision in 31 patients (59% of the total), both an inadequate length and an inadequate depth of septectomy in 13 patients (25%), and both residual subaortic obstruction due to systolic anterior motion of the mitral valve and midventricular obstruction in 2 patients (4%). Preoperatively, 96% of patients were in New York Heart Association class III or IV; postoperatively, 93.8% were in class I or II (P < .001). The 10-year survival after reoperation was 98% and similar to that of an age- and gender-matched Minnesota population (P = .46). The most common cause of recurrent left ventricular outflow tract obstruction and symptoms in patients undergoing septal myectomy has been an inadequate length of septal excision. Reoperation is safe, with excellent long-term survival and functional improvement.

Massive Intercalary Reconstruction of Lower Limb after Wide Excision of Malignant Tumors: An Alternative to Amputation or Rotationplasty

In this study, we present the feasibility of intercalary limb resection and massive reconstruction for malignant tumors of lower extremity. Ten cases of lower extremity malignancies that had undergone concomitant bone (and/or joint) and soft-tissue reconstruction after wide excision exceeding two-thirds of the cross-sectional area of the affected limb were reviewed. All cases were indicated for amputation because of an expansive tumor, hematoma from a pathologic fracture, or previous unplanned excision, with or without critical structure involvement. Bone was reconstructed with either an allograft or a tumor prosthesis. Soft-tissue reconstruction was performed to achieve critical structure and coverage, which was required in all cases. The resection margin was clear in all cases, and no soft-tissue graft failure was encountered. During a mean follow-up of 26 months (range, 9-42 months), no patient developed local recurrence in the resection-reconstruction site. Of the 10 patients, 8 patients were able to walk independently, and two were ambulatory but needed crutch support outdoors. Massive intercalary resection and reconstruction can be an effective treatment option for locally progressed or complicated lower extremity malignancies. Considering patient preference and the fair functional outcomes observed, it may be a useful alternative to amputation or rotationplasty.