Surgery For Other Indications Research Articles

Extremely late recurrence of adult granulosa cell tumor in the retroperitoneal space 27 years after surgery manifesting as a liver tumor.

We present a patient with an extremely late and rare manifestation of recurrent AGCTs. After 27 years, the recurrence of the disease is unlikely, and the manifestation of liver lymphatic cavernoma is not a premise for suspicion of AGCT recurrence. The retroperitoneal site of recurrence is also very rare, and surgical resection of the tumor may not always be possible. We suggest that the decision to resect should always be made if possible. Patients with a history of AGCT should always be carefully considered for surgery for other indications, as even extremely long recurrences are possible.

Minimally invasive interval cytoreductive surgery for advanced ovarian cancer

AbstractWith the increasing use of neoadjuvant chemotherapy, it has also become apparent that some patients will require a less extensive interval cytoreductive surgery which could be performed as a minimally invasive procedure. This observation, and expertise with minimally invasive surgery for other indications in gynecologic oncology, has driven surgeons in the United States and other countries to perform an increasing portion of interval cytoreductive surgery using minimally invasive techniques. Further observational and trial data will continue to inform which patients are best suited for this approach.

Intraoperative hypovolemia as a possible precipitating factor for pituitary apoplexy: a case report

BackgroundPituitary apoplexy is acute infarction with or without hemorrhage of the pituitary gland. It is a rare but potentially life-threatening emergency that most commonly occurs in the setting of pituitary adenoma. The mechanisms underlying pituitary apoplexy are not well understood, but are proposed to include factors of both hemodynamic supply and adenoma demand. In the case of patients with known pituitary macroadenomas undergoing major surgery for other indications, there is a theoretically increased risk of apoplexy in the setting of “surgical stress.” However, risk stratification of patients with nonfunctioning pituitary adenomas prior to major surgery is challenging because the precipitating factors for pituitary apoplexy are not completely understood. Here we present a case in which intraoperative hypovolemia is a possible mechanistic precipitating factor for pituitary apoplexy.Case presentationA 76-year-old patient with a known hypofunctioning pituitary macroadenoma underwent nephrectomy for renal cell carcinoma, during which there was significant intraoperative blood loss. He became symptomatic with ophthalmoplegia on the second postoperative day, and was diagnosed with pituitary apoplexy. He was managed conservatively with cortisol replacement therapy, and underwent therapeutic anticoagulation 2 months after pituitary apoplexy for deep vein thrombosis. His ophthalmoplegia slowly resolved over months of follow-up. Pituitary apoplexy did not recur with therapeutic anticoagulation.ConclusionsWhen considering the risk of surgery in patients with a known pituitary macroadenoma, an operation with possible high-volume intraoperative blood loss may have increased risk of pituitary apoplexy because intraoperative hypovolemia may precipitate ischemia, infarction, and subsequent hemorrhage. This may be particularly relevant in the cases of elective surgery. Additionally, we found that we were able to therapeutically anticoagulate a patient 2 months after pituitary apoplexy for the management of deep vein thrombosis without recurrence of pituitary apoplexy.

Safe Technical Innovation: Development and Implementation of a Robotic Breast Operation Program.

Safe Technical Innovation: Development and Implementation of a Robotic Breast Operation Program.

A novel scoring system for identifying patients at risk for venous thromboembolism undergoing diverticular resection: an American College of Surgeons-National Surgical Quality Improvement ProgramStudy.

Following colorectal surgery, venous thromboembolism (VTE) is a serious complication occurring at an estimated incidence of 2-4%. There is a significant body of literature stratifying risk of VTE in specific populations undergoing colorectal resection for cancer or inflammatory bowel disease. There has been little research characterizing patients undergoing colorectal surgery for other indications, e.g. diverticulitis. We hypothesize that there exists a subgroup of patients with identifiable risk factors undergoing resection for diverticulitis that has relatively higher risks for VTE. We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Project database from 2006 to 2017 who underwent colorectal resection for diverticulitis. Patients with a primary indication for resection other than diverticulitis were excluded. Multivariate logistic regression modeling was conducted to determine the risk of VTE for each independent variable. A novel scoring system was developed and a receiver-operating-characteristic curve was generated. The rate of VTE was 1.49%. An 7-point scoring system was developed using identified significant variables. Patients scoring ≥ 6 on the developed scoring scale had a 3.12% risk of 30-day VTE development. A simple scoring system based on identified significant risk factors was specifically developed to predict the risk of VTE in patients undergoing diverticular colorectal resection. These patients are at significantly higher risk and may justify increased vigilance regarding VTE events, similar to patients undergoing colorectal resection for cancer or inflammatory bowel disease.

Primary prevention of ovarian cancer: a patient decision aid for opportunistic salpingectomy

The discovery of the fallopian tube epithelium as the origin of high-grade serous ovarian cancer has brought a new option for ovarian cancer prevention. The fallopian tubes have no known function after completion of childbearing and can be removed to reduce the lifetime risk of ovarian cancer. Although the lifetime risk in the general population does not justify preventive surgery in itself, salpingectomy can be performed during abdominal surgery for other indications, also known as an opportunistic salpingectomy. The popularity of opportunistic salpingectomy is increasing worldwide; however, the variation between gynecologists and hospitals in their advice on opportunistic salpingectomy occurs because of the remaining uncertainty of evidence. Therefore, whether a woman can make her own decision depends on the hospital or gynecologist she visits. We aimed to lower this practice variation by providing standardized and unbiased counseling material. We aimed to develop and test a patient decision aid for opportunistic salpingectomy in women undergoing pelvic gynecologic surgery to either retain the ovaries or opt for sterilization. We followed a systematic development process based on the International Patient Decision Aid Standards. Data were collected between June 2019 and June 2020, using both qualitative and quantitative methods. The development process that occurred in collaboration with patients and healthcare professionals was overseen by a multidisciplinary steering group and was divided into 4 phases: (1) assessment of decisional needs using individual telephone interviews and questionnaires; (2) development of content and format based on decisional needs, current literature, and guidelines; (3) alpha testing and the first revision round; and (4) alpha testing and the second revision round. An outline of the patient decision aid was developed on the basis of decisional needs, current literature, and guidelines. It became clear that the decision aid should consist of 2 separate paths: one with information specifically for salpingectomy in addition to abdominal surgery and one for salpingectomy as a sterilization method. Both paths contained information on the anatomy and function of ovaries and fallopian tubes, risk reduction of ovarian cancer, and potential benefits and risks of opportunistic salpingectomy. Moreover, the sterilization path contains information on various sterilization methods and risks of unwanted pregnancy. The patient decision aid was developed as an online tool that includes information chapters, a knowledge quiz, consideration statements, and a summary detailing the patient's preferences and considerations. Adjustments were made following alpha testing round 1. The improved patient decision aid was subjected to usability tests (alpha testing round 2), in which it scored an "excellent" in tests with patients and a "good" in tests with gynecologists. Furthermore, our patient decision aid met the requirements of 45 of 49 applicable items from the International Patient Decision Aid Standards criteria. In collaboration with patients and healthcare professionals, a patient decision aid was developed on opportunistic salpingectomy and salpingectomy as a sterilization method. Both patients and gynecologists believed it is a useful tool that supports patients in making an informed decision whether to undergo an opportunistic salpingectomy and supports the counseling process by gynecologists.

Recommandations pour Pratique Clinique du Collège des Gynécologues Obstétriciens français 2021 : gestes prophylactiques associés en chirurgie gynécologique

ObjectiveTo draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications. DesignA consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded. MethodsThe panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation. ResultsThe literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/−) and 28 by low-quality evidence (GRADE 2+/−). Recommendations on two questions were left ungraded due to a lack of evidence in the literature. ConclusionsA high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

Postoperative opioid use for patients with chronic pelvic pain undergoing robotic surgery for resection of endometriosis.

We aimed to identify the amount of opioids used in the postoperative setting for patients with a history of chronic pelvic pain undergoing robotic surgical excision of endometriosis and compare this to patients undergoing benign robotic gynecologic surgery for other indications. We conducted a retrospective cohort study in an urban academic university hospital from January 2019 to March 2020. Data regarding opioid use was collected via a patient-reported survey that was given at the 3weeks follow-up visit. Data regarding opioid use was compared to patients undergoing robotic surgery for other benign gynecologic indications. Our study included 158 patients, 119 undergoing surgery for endometriosis and 39 patients undergoing robotic surgery for other benign gynecologic indications. Patients undergoing surgery for endometriosis used on average 105.9 morphine milligram equivalents (MME), equivalent to 14 tabs of oxycodone 5mg. There was no statistically significant difference in the amount of opioids used postoperatively based on stage of endometriosis or need for hysterectomy. Patients undergoing surgery for other benign indications used on average 49.4 MME, equivalent to 6 tabs of oxycodone 5mg. The difference in amount of opioids used between patients with and without endometriosis was statistically significant. In conclusion, patients undergoing robotic surgery for endometriosis used over two times as many opioids postoperatively as patients without endometriosis and have a higher perceived postoperative pain. Providers should be aware of this difference in order to provide better pain control for this patient population.

Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study.

Objective:Examine the association of Graves’ disease with the development of postoperative neck hematoma.Design:A cohort of patients participating in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016 to December 31, 2018.Setting:A North American surgical cohort study.Methods:17 906 patients who underwent thyroidectomy were included. Propensity score matching was performed to adjust for differences in baseline covariates. Multivariate logistic regression was used to ascertain the association between thyroidectomy for Graves’ disease and risk of postoperative adverse events within 30 days of surgery. The primary outcome was postoperative hematoma. Secondary outcomes were postoperative hypocalcemia and recurrent laryngeal nerve injury.Results:One-to-three propensity score matching yielded 1207 patients with mean age (SD) of 42.6 (14.9) years and 1017 (84.3%) female in the group with Graves’ disease and 3621 patients with mean age (SD) of 46.7 (15.0%) years and 2998 (82.8%) female in the group with indications other than Graves’ disease for thyroidectomy. The cumulative 30-day incidence of postoperative hematoma was 3.1% (38/1207) in the Graves’ disease group and 1.9% (70/3621) in other patients. The matched cohort showed that Graves’ disease was associated with higher odds of postoperative hematoma (OR 1.65, 95% CI 1.10-2.46) and hypocalcemia (OR 2.04, 95% CI 1.66-2.50) compared with other indications for thyroid surgery. There was no difference in recurrent laryngeal nerve injury among the 2 groups.Conclusions:Patients with Graves’ disease undergoing thyroidectomy are more likely to suffer from postoperative hematoma and hypocalcemia compared to patients undergoing surgery for other indications.

Gastrointestinal Stromal Tumors (GISTs) as Incidental Findings in Gynecological Surgery.

Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gastrointestinal tract that may be diagnosed incidentally as a part of intra-abdominal surgery for other diseases. This is a single center review to document the incidental finding of GIST at surgery for gynecological malignancies during a 10-yr period. Sixteen cases of incidental GISTs were identified in women ranging in age from 39 to 82 yr. GISTs presented as incidental secondary lesions in women undergoing surgery for other indications, typically primary debulking surgery for tubo-ovarian high-grade serous carcinoma. The GIST was located in the stomach wall in 9 cases. Other sites were cecum, omentum, and mesentery. Diagnosis of GIST was supported by immunohistochemistry in all cases and by molecular studies in 3 cases. Seventy-five percent of cases were micro-GISTs, measuring <2 cm in diameter and, where Miettinen and Lasota criteria could be applied, fitted into "no risk," "very low risk" or "low risk" prognostic groups. Seventy-five percent of women for whom survival data was available, showed disease-free survival at follow-up. The 2 women who died had concurrent high stage or high-grade gynecological malignancy at initial diagnosis.

Articulating vs Static Spacers for Native Knee Infection in the Setting of Degenerative Joint Disease.

BackgroundPatients with advanced knee arthritis who develop a septic joint are not adequately treated with irrigation and debridement and intravenous antibiotics because of antecedent cartilage damage. The gold standard treatment has been a 2-stage approach. The periprosthetic joint infection literature has demonstrated the superiority of articulating spacers, and metal-on-poly (MOP) spacers are being used with increasing frequency. The purpose of this study was to compare the postoperative outcomes of patients with infected, arthritic knees treated by a 2-stage approach to those of patients who received single-stage treatment with a MOP spacer.MethodsSixteen patients with native knee septic arthritis treated with an antibiotic spacer between 1998 and 2019 were reviewed. Demographic data, clinical data, knee motion, Knee Society score, Timed-Up-and-Go, and pain scores were collected. Survivorship of final implants was compared.ResultsSix of 16 knees (38%) received single-stage treatment, and 10 received 2-stage treatment (62%). Five of 6 MOP spacers (83%) were retained at a mean follow-up of 3 ± 1.2 years. Nine of 10 (90%) receiving static spacers had subsequent reconstruction, with 9 (100%) surviving at mean follow-up of 7 ± 3.2 years. The patients who received MOP spacers trended toward greater terminal flexion, higher Knee Society score, and faster Timed-Up-and-Go at final follow-up.ConclusionInfection in a native, arthritic knee may be effectively treated using single-stage MOP spacer. Postoperative outcomes of single-stage MOP spacers compare favorably to staged static spacers and with those undergoing revision surgery for other indications. Longer follow-up is needed to evaluate durability of MOP spacers.

Abstract 13461: Longitudinal Evolution of Epicardial Pacing Leads

Introduction: Implantation of epicardial pacing leads remains a well-known alternative to the standard transvenous approach in several situations. However, long-term data on the performance and safety of epicardial pacing leads remain scarce. Methods: We conducted a retrospective cohort study at a single tertiary center including all patients with right or left ventricular epicardial lead implantation between 1996 to 2018; n=255. Electrophysiological lead parameters at implantation and during follow-up were analyzed and compared with clinical data from the electronic medical records. Results: 230 patients were included in the analysis. Implanted lead models included the Medtronic 4968 (n=202) and Medtronic 5071 (n=28). Indications for epicardial lead implantation included upgrade to CRT in 153/230 (67%) individuals and standard right or left ventricular pacing only in 76/230 (33%). Of the 153 epicardial CRT patients, 50 had a history of failed transvenous CRT and 103 had concomitant cardiac surgery for other indications and were thought to have a likely indication for CRT in the nearby future. Mean follow-up time was 4,7years±4,2. Lead impedances were significantly higher in the 4968 model compared to the 5071. Pacing thresholds for both lead models were similar at implantation but were subsequently significant higher in the 5071 model. Higher pacing thresholds in the 5071 model did not result in premature battery depletion. Periprocedural complications related to the epicardial lead insertion occurred in 3/230 patients. Epicardial lead related complications at follow-up remained low (8/230; 3 dysfunctions, 2 dislodgments, 1 impending skin erosion). There were only 2 cases of epicardial lead infections at follow-up requiring surgical extraction. 4,3% of all implanted leads remained unconnected at follow-up. Conclusions: Epicardial lead implantation for either CRT or pacing indications is a durable and safe alternative to transvenous lead insertion.

S0133 Incidence and Predictors of New Onset Diabetes Mellitus Following Surgical Resection of Pancreatic Cystic Lesions

INTRODUCTION: There is a risk of new onset diabetes mellitus (NODM) following pancreatic resection. Compared with patients who undergo surgery for other indications, including acute and chronic pancreatitis and pancreatic adenocarcinoma, patients with pancreatic cystic lesions (PCLs) generally have normal adjacent pancreatic parenchyma. However, the risk of post-operative diabetes mellitus (DM) among patients with PCLs is poorly defined. Therefore, the objective of the current study was to characterize the incidence and risk factors associated with NODM following pancreatectomy for PCLs. METHODS: The Truven MarketScan Research Database (2012–2018) was utilized to identify all adult subjects with PCLs and without prevalent DM who underwent a pancreatic resection. Stringent exclusion criteria (Figure 1) were utilized to isolate only those patients without other diseases of the exocrine pancreas. A time to event analysis using Kaplan-Meier curves and multivariable Cox proportional hazards analysis was conducted to identify incidence and risk factors associated with post-operative NODM. RESULTS: Among 311 subjects with PCLs who underwent partial pancreatectomy, the overall risk of post-operative DM was 9.1% (95% CI 6.3%–12.9%) at 6 months, 15.1% (95% CI 11.3%–20.2%) at 1 year, and 20.2% (95% CI 15.3%–26.4%) at 2 years. In a multivariable Cox proportional hazards model, older age (55–64 years, adjusted Hazard Ratio (aHR) 1.97, 95% CI 1.04–3.72 vs. 18–54 years), obesity (aHR 2.63, 95% CI 1.35–5.12), hypertension (aHR 1.79, 95% CI 1.01–3.17) and cardiovascular disease/heart failure (aHR 2.54, 95% CI 1.02–6.28) were independent predictors of post-operative NODM. Moreover, there was no significant difference in risk of NODM after distal pancreatectomy versus pancreaticoduodenectomy (unadjusted HR 1.41, 95% CI 0.69–2.88) in this population. CONCLUSION: In a large population-based cohort, the risk of NODM following pancreatectomy for PCL was not excessive, and was relatively higher in older patients with features of metabolic syndrome and/or cardiovascular disease. Individuals with these clinical characteristics may benefit from peri- and post-operative monitoring, education, and treatment strategies for DM.Figure 1

Predicting factors of ocular hypertension following keratoplasty: Indications versus the procedure.

To assess the incidence of ocular hypertension (OHTN) following penetrating keratoplasty (PKP) versus deep anterior lamellar keratoplasty (DALK) corneal transplant surgeries, and to assess the impact of indication for transplantation versus surgery type on OHTN development. A retrospective study of 76 eyes of 76 patients who underwent PKP or DALK between 1 January 2009 and 1 September 2014. Data included: preoperative intraocular pressure (IOP), indication and type of surgery, post-surgical IOP at 1 to 5, 14 to 21 days, 3, 6 months, 1 year and at the last follow up. Primary outcome was post-operative OHTN (defined as IOP >21 mm Hg). A total of 13 patients (17.1%) developed OHTN of whom 9 (20.45%) underwent PKP and 4 (12.5%) DALK (p = 0.33). OHTN occurred after an average of 16.46 ± 8.47 months (0.1-58 months). Twenty-one keratoconus patients (39.62%) underwent PKP and 32 (60.37%) underwent DALK. Patients with indications other than keratoconus all underwent PKP. Keratoconus patients were less likely to develop OHTN (9.43% vs 34.78%, p = 0.02). Among patients developing OHTN, mean age of the non-keratoconus group was significantly higher (63.25±16.7 vs 33 ± 10, p = 0.01). No significant difference in OHTN among keratoconus patients undergoing DALK versus PKP (12.5% vs 4.76%, respectively, p = 0.35) was found. PKP was associated with less OHTN in keratoconus eyes (4.76% vs 34.78%, p = 0.02). Patients who underwent keratoplasty due to keratoconus are at a lower risk to develop OHTN than those who underwent surgery for other indications.

Embolic risk stratification and prognostic impact of early surgery in left-sided infective endocarditis

In patients with left-sided infective endocarditis (IE) and heart failure associated with large vegetations, early surgery prevents embolic events. However, optimal timing of surgery for other indications is still unresolved particularly when the presence of large vegetations represents the sole indication. We retrospectively analyzed 308 consecutive patients admitted to our department with definite left-sided IE. Of these patients, 243 (79%) underwent cardiac surgery (complicated IE), 34 patients with uncomplicated IE received medical treatment, 24 were not operated due to prohibitive general conditions and 7 refused surgery. Long-term follow-up was obtained by structured telephone interviews. During the 6-year follow-up (average 121.8 weeks ± 76), patients not operated because of general conditions or refusal had the worst prognosis, while outcome in operated patients for complicated IE was comparable to that of uncomplicated IE treated medically. Early (<2 weeks from diagnosis) surgery was associated with better survival compared to delayed surgery (HR 0.58, p=0.23). Embolic events were detected at admission in 38% of cases; Staphylococcus Aureus etiology and vegetation size were independently associated with embolism (OR 2.4, p=0.01; OR 1, p=0.008 respectively). Compared to uncomplicated medically-treated patients, complicated IE showed comparable survival when managed aggressively by surgical intervention, whereas a conservative approach was associated with an adverse prognosis. Staphylococcus Aureus infection and vegetation size were independent predictors of systemic embolism. Our data support aggressive surgical management of complicated IE patients and highlight the importance of etiological characterization in clinical decision-making.

V13-12 ADNEXAL MANAGEMENT AT THE TIME OF ELECTIVE PELVIC SURGERY IN WOMEN

You have accessJournal of UrologyFemale Pelvic Surgery (V13)1 Apr 2020V13-12 ADNEXAL MANAGEMENT AT THE TIME OF ELECTIVE PELVIC SURGERY IN WOMEN Adam Miller*, David Yang, and Brian Linder Adam Miller*Adam Miller* More articles by this author , David YangDavid Yang More articles by this author , and Brian LinderBrian Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000970.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ovarian cancer has the highest mortality rate of all gynecologic cancers and is the fifth leading cause of cancer mortality in women with a lifetime risk of 1.4%. Despite advances in medicine, there has only been marginal improvement in survival over the past 50 years, mainly due to limited screening. It is known that many ovarian cancers are derived from the fallopian tube and not directly from the ovary. As such, opportunistic salpingectomy with or without oophorectomy has been proposed as a way to decrease ovarian cancer risk in patients undergoing routine pelvic surgery for other indications. The objective of our video is to discuss the role, feasibility, and surgical technique of opportunistic salpingectomy with or without oophorectomy for ovarian cancer risk reduction at the time of open, laparoscopic, or robotic pelvic surgery for another indication. METHODS: We present opportunistic salpingectomy and salpingo-oophorectomy in three patients. The first two cases highlight examples of this technique performed during robotic pelvic surgery and the third case is an example performed during open pelvic surgery. RESULTS: In our video, salpingectomy and salpingo-oophorectomy are performed with minimal added operative time or blood loss. No complications occurred due to the additional procedure. CONCLUSIONS: Salpingectomy and salpingo-oophorectomy for ovarian cancer risk reduction is a safe, feasible option for patients undergoing pelvic surgery. Surgeons familiar with operating in this location should consider opportunistic salpingectomy or salpingo-oophorectomy in females who are no longer interested in fertility preservation and who are undergoing routine pelvic surgery for another indication. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1214-e1214 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam Miller* More articles by this author David Yang More articles by this author Brian Linder More articles by this author Expand All Advertisement PDF downloadLoading ...

Left Atrial Appendage Mechanical Exclusion: Procedural Planning Using Cardiovascular Computed Tomographic Angiography.

Left atrial appendage (LAA) mechanical exclusion is being investigated for nonpharmacologic stroke risk reduction in selected patients with atrial fibrillation. There are multiple potential approaches in various stages of development and clinical application, each of which depends on specific cardiothoracic anatomic characteristics for optimal performance. Multiple imaging modalities can be utilized for application of this technology, with transesophageal echocardiography used for intraprocedural guidance. Cardiovascular computed tomographic angiography can act as a virtual patient avatar, allowing for the assessment of cardiac structures in the context of surrounding cardiac, coronary vascular, thoracic vascular, and visceral and skeletal anatomy, aiding preprocedural decision-making, planning, and follow-up. Although transesophageal echocardiography is used for intraprocedural guidance, computed tomographic angiography may be a useful adjunct for preprocedure assessment of LAA sizing and anatomic obstacles or contraindications to deployment, aiding in the assessment of optimal approaches. Potential approaches to LAA exclusion include endovascular occlusion, epicardial ligation, primary minimally invasive intercostal thoracotomy with thoracoscopic LAA ligation or appendectomy, and minimally invasive or open closure as part of cardiothoracic surgery for other indications. The goals of these procedures are complete isolation or exclusion of the entire appendage without leaving a residual appendage stump or residual flow with avoidance of acute or chronic damage to surrounding cardiovascular structures. The cardiovascular imager plays an important role in the preprocedural and postprocedural assessment of the patient undergoing LAA exclusion.

Urinary tract infection after clean-contaminated pelvic surgery: a retrospective cohort study and prediction model.

Postoperative urinary tract infection (UTI) leads to increased patient morbidity and health care costs. A prediction model may identify patients at highest risk for UTI development. Our primary objective was to determine the rate of UTI in the first 6weeks after benign gynecologic surgery. Our secondary objective was to identify risk factors and build a predictive model for postoperative UTI. We reviewed 310 patient records, which represent all patients who underwent clean-contaminated surgery at a tertiary center (2016-2017). UTI was defined as positive urine culture (> 100,000,000CFU/l) in a symptomatic patient. Pre-, intra- and postoperative variables were collected. The relation between these variables and UTI was assessed through logistic regression. A clinical prediction model was built. Patients' mean age was 58.5years and mean body mass index was 27.5kg/m2. Most were inpatients (65.8%) and 269 had urogynecologic procedures, with the remainder undergoing pelvic surgery for other indications. The most common operation was vaginal reconstruction for prolapse (59.7%), associated with concomitant synthetic midurethral sling in 1/3 cases. Forty patients (12.9%) developed UTI. Multivariate prediction modeling showed increasing age (OR 1.33, CI 1.01-1.75), increasing number of procedures (OR 1.42, CI 1.14-1.78) and prolonged voiding dysfunction (OR 3.78, CI 1.66-8.60) to be significant UTI predictors. Urinary tract infection in the first 6weeks after complex pelvic surgery is common. Our prediction model identifies that patients who are older women, have prolonged voiding dysfunction and have a greater number of concomitant pelvic floor surgeries have higher risk of postoperative UTI.

Endosearch: The International Clinical Trial to Test a Cluster of Biomarkers to Diagnose Endometriosis

Study Objective The aim of our study is to test a combination of biological markers differentially expressed in samples from women with or without endometriosis. Methods Design ENDOSEARCH is a prospective multicentric international clinical trial registered with Clinical Trial.gov. Setting 20 renowned specialized centers in Europe, USA, Canada, and the Indian Ocean, granted by the European Union aiming to validate a cluster of biomarkers. Patients or Participants 1000 patients. The Patient Group includes women between 18 and 45 with suspected endometriosis undergoing laparoscopy. Patients with predominant adenomyosis and/or fibroids diagnosed by imaging, chronic, malignant, infectious, metabolic or endocrine diseases are excluded. The Control Group includes patients of same age group without any endometriosis-related clinical sign, with planned laparoscopic surgery for other indications. Samples of endometriosis lesions and endometrial biopsies for both groups are sent to a unique center (Endodiag, Paris, France) to be tested with the cluster of biomarkers. Interventions Laparoscopy for endometriosis or benign conditions (Control group). Measurements and Main Results 40% of the patients recruited in the Endometriosis group have already had at least one and up to 4 previous laparoscopies for endometriosis. Almost 50% of the patients had an AFS score of III or IV. 14% of the patients suspected of endometriosis had negative pathology while 2% of the patients in the control group had severe endometriosis at laparoscopy and were excluded. Conclusion We present the first large prospective multicentric international clinical trial aiming to test a cluster of biomarkers to diagnose endometriosis by recruiting over 1000 patients all around Europe, the US and Canada. Even in major referral centers almost 14% of the pre-op diagnosis were negative at pathology while 2% of the control group had severe endometriosis. Those preliminary results with others show the necessity of development of accurate biological tests to diagnose endometriosis and avoid unnecessary laparoscopies.

2462 Don't Forget the Appendix! Incidental Appendix Findings During Laparoscopic Pelvic Surgery

Study Objective Evaluate the incidence of appendectomy for grossly abnormal appearance during laparoscopic gynecologic surgery for benign indications and pathologic concordance. Design Retrospective chart review of patients who underwent an appendectomy during laparoscopic gynecologic surgery for other indications. Setting Surgeries by Advanced Gynecologic Surgery Institute (AGSI), a group of three highly skilled minimally invasive gynecologic surgeons, at three community hospitals in the Chicago area. Patients or Participants A total of 3,478 patients underwent laparoscopic surgery by AGSI between January 1, 2013 through February 28, 2018. Seventy-three patients underwent appendectomy, and fifty-six were included in final analysis. All patients were 18 years of age or older with available operative and pathology reports. Interventions IRB approval was obtained and a retrospective chart review conducted using outpatient and inpatient electronic medical records. Measurements and Main Results Patients were assessed for age, body mass index, surgical indication, procedure performed, intra-operative appendiceal findings, blood loss, pathology, intra-operative events, and postoperative complications. Intraoperatively, the most common indication for appendectomy was endometriosis or fibrosis (61.8%) of which 58.8% had confirmatory pathology and 23.5% had normal pathology. Overall, 75.0% of the specimens were positive for a pathologic process. Four (7.2%) appendiceal malignancies were found, three mucinous and one carcinoid tumor. All three patients with mucinous tumors were operated on by a general surgeon, at same time of gynecologic surgery (1) or at a later date (2). No significant sequelae occurred. Conclusion The appendix should be evaluated during gynecologic laparoscopy, as incidental findings may be identified including malignancies. It is safe for trained gynecologists to perform a laparoscopic appendectomy, but a general surgeon should be consulted intra-operatively when a suspicious mass or malignancy is noted. Future research could evaluate postoperative pain profiles, increased costs and surgical time, and incidence of appendiceal pathology in the endometriosis population.