Surgery For Recurrence Research Articles

THU101 A Challenging Case Of Recurrent Suprasellar Epidermoid Cyst With Visual Field Deficits

Abstract Disclosure: S. Ahsun: None. A. Atri: None. R. Bhat: None. C. eaton: None. N. Blocher: None. A challenging case of recurrent suprasellar epidermoid cyst with visual field deficits. Introduction: Intracranial epidermoid cysts account for approximately 1% of all intracranial tumors. The most common location of occurrence is cerebellopontine angle. Suprasellar region is the second most common location. We present a case for suprasellar epidermoid cyst with visual field deficits. Case Presentation: A 52 y/o female presented to an ophthalmologist for blurring of vision and was found to have bitemporal hemianopia. MRI of the brain showed a large suprasellar mass of 6.9x4.2x3.3 cm with extension into the surrounding structures. A portion of the cyst wall was hemorrhagic. There was significant mass-effect on the optic chiasm and bilateral optic tracts. Patient underwent elective craniotomy with left frontotemporal approach. A characteristic pearly wide epidermoid capsule was visualized through the oculomotor triangle. The optic nerve was noted to be quite distorted in its course, exiting from the optic canal and being pushed superiorly by the epidermoid tumor. Accessible tumor capsule was resected, however due to the dense adhesions of the epidermoid cyst to the surrounding vasculature and the optic nerves, complete resection was not attempted. Postoperatively, patient developed right-sided hemiparesis due to an acute infarct. Patient also developed some dementia, hyperphagia and aggressive behavior following her surgery. She started her rehabilitation therapy but had persistent dementia and cognitive decline. Repeat vision testing showed right superior homonymous hemianopia. MRI of the brain a year after the initial surgery showed growth of the residual cyst and some obstructive hydrocephalus but without any symptoms. She underwent a second debulking procedure that was successful with complete excision of the residual tumor but the patient had delayed recovery. She subsequently underwent tracheostomy and PEG tube placement and was transferred to the rehabilitation facility. She is now awake but still nonverbal. Patient also developed panhypopituitarism and is currently on the replacement for cortisol and thyroid hormone. She is also on DDAVP for her diabetes insipidus which seems to be permanent in her case. Conclusion: This case highlights some important facts: 1. Epidermoid cysts are challenging from the management standpoint. Only 50-80% can be resected completely. Incomplete removal increases the chances for recurrence which are variable at 1-54%. 2. Even in cases of recurrent growth repeat surgery should only be performed if patient has significant symptoms from the tumor. 3.As per the literature patients with adjuvant radiotherapy have improved outcomes. As in our case radiotherapy should have been considered in the setting of recurrence of the tumor. 4.Endoscopic endonasal approach is a new modality that has shown a very low rate of complications after resection. Presentation: Thursday, June 15, 2023

SAT202 A Case Of Primary Hyperparathyroidism Secondary To Ectopic Intrathymic Parathyroid Adenoma

Abstract Disclosure: S. Pandiri: None. Introduction: Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia. Majority of cases are due to a single adenoma. In about 6-16% of cases, the parathyroid adenoma is in an ectopic location. Accurate preoperative imaging is key in localizing ectopic parathyroid adenomas. Clinical Case: 64 year old man with hypercalcemia was referred to endocrinology for further evaluation. His symptoms included fatigue, nausea, polydipsia and polyuria. There was no history of fractures, radiation therapy or family history of hypercalcemia. The patient’s past medical history is significant for nephrolithiasis, thyroid nodules and hypertension. He was started on Cinacalcet 30 mg, twice daily, by his primary care physician about 6 weeks prior to the initial visit. Physical exam was unremarkable. Lab studies were significant for elevated albumin-corrected calcium: 11.2 mg/dl (8.6-10.3 mg/dl), elevated PTH: 578.1 pg/ml (12-88 pg/ml), 25-OH vitamin D: 17 ng/ml (>30 ng/ml), phosphorus: 2 mg/dl (2.5-4.5 mg/dl) TSH: 0.54 mIU/L (0.40-4.50 mIU/L), 24 hr urine calcium: 429 mg (<250 mg/24 hr). The lab findings were consistent with hypercalcemia due to primary hyperparathyroidism. Neck Ultrasound showed bilateral thyroid nodules but no parathyroid adenoma. Tc-99m sestamibi scintigraphy was significant for 2.8 x 1.5 x 3.4 cm mass in the anterior mediastinum but did not show uptake in the neck. CT Neck showed a mass in the anterior mediastinum measuring 1.6 x 2.7 cm. Bone density was significant for osteopenia. He underwent robot assisted mediastinal mass excision two months after the initial evaluation. The pathology was significant for ectopic, intrathymic parathyroid adenoma, watery cell type with nuclear atypia, measuring 3.8 x 3.1 x 1.3 cm. Labs at the follow up visit showed normal albumin-corrected calcium of 8.6 mg/dl, improved PTH of 110.3 pg/ml. His symptoms improved significantly after surgery. Conclusion: This case demonstrates that preoperative localization of an ectopic parathyroid adenoma can prevent recurrent surgeries and persistent hypercalcemia. It is important for physicians to be aware of the various ectopic locations of parathyroid adenomas during the diagnostic workup of PHPT. Reference: Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg. 2013 Jan;37(1):102-6. doi: 10.1007/s00268-012-1773-z. PMID: 22968537. Presentation: Saturday, June 17, 2023

Recurrent Toe Walking in Pediatric Orthopedic Patients: Idiopathic vs Concomitant Sensory Processing Disorders

Category: Other Introduction/Purpose: The purpose of this study is to compare rates of recurrent toe-walking following operative intervention between idiopathic toe walkers and toe walkers with associated sensory processing/autism spectrum disorders. Methods: An IRB-approved retrospective review of patients at a single pediatric institution who underwent surgical treatment for toe-walking over a 12-year period was conducted. Children with peripheral or central neurologic disorders, muscle disorders, congenital foot/extremity deformities, prior ankle/foot surgery, and those not managed with an isolated triceps surae procedure were excluded. The remaining patients were divided into those with idiopathic toe-walking (ITW Group) and those with toe- walking associated with sensory processing/autism spectrum disorders (SPD Group). Recurrence of toe walking and need for additional surgery for recurrence were compared between cohorts. Recurrence rates and subsequent operations were assessed for each group. Multivariate regression and Fischer exact test were used to evaluate differences in group characteristics. Results: 106 patients met inclusion criteria. 29 patients (27%) had an associated sensory processing disorder, the remaining 77 patients comprised the ITW group. There were no differences between groups in length of follow-up (p=0.08) or type of initial surgery performed (p=0.48). The SPD group contained a significantly greater percentage of males (75% vs 56%, p=0.01) and were younger at the age of index surgery (8.5 vs 10 years, p=0.03). At an average follow-up time of 1.2 years, 11 patients (10%) developed clinical recurrence, of whom, 4 underwent a subsequent intervention. The SPD group had significantly higher rates of recurrence than idiopathic toe walkers (24% vs 5%, p=0.009). Multivariate regression analysis demonstrated that an underlying sensory processing disorder was an independent predictor of recurrence (p=0.018, OR=7.5). Conclusion: Clinical recurrence following the surgical treatment of toe-walking is over seven times greater in children with autism spectrum and/or other sensory processing disorders than idiopathic counterparts.

KONO-S Anastomosis Is Not Superior to Conventional Anastomosis for the Reduction of Postoperative Endoscopic Recurrence in Crohn's Disease.

Surgical resection rates remain high in Crohn's disease (CD). Reducing postoperative recurrence (POR) is challenging. Besides drug therapy, the surgical anastomosis technique may reduce POR. We aimed to compare the endoscopic POR rate after Kono-S vs standard ileocolic anastomosis. The study included all consecutive CD patients operated on for ileocolic resection with a Kono-S anastomosis between February 2020 and March 2022. These patients were prospectively followed, and colonoscopy was performed 6 to 12 months after surgery. Patients were compared with a historical cohort of patients operated on with a conventional anastomosis in the same center. The primary end point was endoscopic POR (Rutgeerts score ≥i2). Factors associated with POR were assessed by univariate and multivariable analyses. A total of 85 patients were included, 30 in the Kono-S group and 55 in the control group. At baseline, there was no significant difference between the 2 groups regarding CD characteristics or known POR risk factors, including previous exposure to biologics. At 6 to 12 months, endoscopic POR rate did not differ significantly between groups (56.7% in the Kono-S group vs 49.1% in the control group; P = .50), nor did endoscopic POR according to the modified Rutgeerts score ≥i2b (46.7% in the Kono-S group vs 40% in the control group; P = .55). Severe endoscopic POR rates were 23.3% and 18.2% in each group, respectively. Clinical recurrence rate was similar in both groups, and no recurrent surgery occurred. By multivariable analysis, the type of anastomosis was not associated with endoscopic POR (OR, 1.229; 95% CI, 0.461-3.274, P = .68); however, postoperative treatment with anti-TNF was (OR, 0.337; 95% CI, 0.131-0.865 P = .02). Kono-S anastomosis was not associated with a reduced rate of endoscopic POR. These results warrant confirmation in prospective, randomized, multicenter studies.

Factors Affecting Recurrence of Idiopathic Granulomatous Mastitis: A Systematic Review.

Idiopathic granulomatous mastitis is a rare and benign disease that primarily affects young women of reproductive age. Various factors have been suggested as possible causes, including pregnancy, breastfeeding, history of taking birth control pills, hyperprolactinemia, smoking, and history of trauma. Due to unknown etiology, opinions on its treatment have varied, resulting in differing recurrence rates and side effects. Therefore, conducting a comprehensive systematic review and meta-analysis can aid in understanding the causes and recurrence of the disease, thereby assisting in the selection of effective treatment and improving the quality of life. A systematic literature review was conducted using predefined search terms to identify eligible studies related to risk factors and recurrence up to June 2022 from electronic databases. Data were extracted and subjected to meta-analysis when applicable. A total of 71 studies with 4735 patients were included. The mean age of the patients was 34.98 years, and the average mass size was 4.64 cm. About 3749 of these patients (79.17%) were Caucasian. Patients who mentioned a history of pregnancy were 92.65% with 76.57%, 22.7%, and 19.7% having a history of breastfeeding, taking contraceptive pills, and high prolactin levels, respectively. Around 5.6% of patients had previous trauma. The overall recurrence rate was 17.18%, with recurrence rates for treatments as follows: surgery (22.5%), immunosuppressive treatment (14.7%), combined treatment (14.9%), antibiotic treatment (6.74%), and observation (9.4%). Only antibiotic and expectant treatments had significant differences in recurrence rates compared to other treatments (p value = 0.023). In conclusion, factors such as Caucasian race, pregnancy and breastfeeding history, and use of contraceptive hormone are commonly associated with the disease recurrence. Treatment should be tailored based on symptom severity and patient preference, with surgery or immunosuppressive options for recurrence.

RAD51D Secondary Mutation-Mediated Resistance to PARP-Inhibitor-Based Therapy in HGSOC.

Ovarian cancer is the leading cause of gynecologic cancer-related death, and PARP inhibitors (PARPis) are becoming a promising treatment option, as demonstrated by recent clinical trials. After PARPi exposure, somatic reversion mutations in the homologous recombination genes may be a mechanism of PARPi resistance in ovarian carcinoma. We present an ovarian cancer case of a 61-year-old woman, who underwent routine tumor reduction surgery followed by platinum and PARPis. She demonstrated a good response to PARPis for 15 months before recurrence and secondary tumor reduction surgery. However, post-surgery platinum and PARPi treatment only kept the disease stable for 5 months. A potential molecular mechanism for PARPi resistance was investigated using next-generation sequencing, immunohistochemical (IHC) staining, and other functional assays. A germline RAD51D loss-of-function mutation was found in the reported case (LRG_516t1:c.270_271dup p1:p.(Lys91fs*13)). Subsequently, a secondary mutation (LRG_516t1:c.271_282 del) was identified in the same locus of the germline duplication in the post-progression biopsies and ctDNA. The IHC staining supported low expression of RAD51D in the initial tumor tissue, but the expression was restored after the correction of the open reading frame by the secondary mutation. The in vitro results supported that the loss-of-function mutation of RAD51D was the basis for the initial response to the platinum and PARPi therapy, while the newly acquired reversion mutation could be attributed to the observed PARPi resistance. An acquired mutation can reverse a loss-of-function change in RAD51D and can result in PARPi resistance in a hereditary ovarian cancer patient. Liquid biopsy could be considered for longitudinal monitoring in ovarian patients under PARPi-based therapy, which can identify acquired resistant mutations earlier and facilitate precision management.

Outcome comparison between primary and revisional bariatric surgery: A propensity-matched analysis

BackgroundRevisional bariatric procedures for weight recurrence are rising but are considered higher risk and less effective than primary bariatric procedures. This study aimed to compare clinical outcomes between primary and revisional bariatric surgery for weight recurrence. MethodsProspectively collected data from adult patients who underwent revisional or primary bariatric surgery from 2016 to 2020 in an academic institution were reviewed. Roux-en-Y gastric bypass and sleeve gastrectomy were performed primarily or as conversion procedures after laparoscopic adjustable gastric band, vertical banded gastroplasty, and sleeve gastrectomy. 1:1 propensity score matching was performed between revisional bariatric surgery and primary bariatric surgery, and logistic regression analysis was used to compare up to 2-year weight loss and comorbidity resolution outcomes. ResultsA total of172 cases (86 revisional bariatric surgery versus 86 primary bariatric surgery) were included. Groups were matched for age, sex, preoperative body mass index, bariatric procedure, diabetes, hypertension, and obstructive sleep apnea. Procedure duration (203 ± 78 vs 154 ± 69 minutes; P < .001) and length of stay (2.3 ± 2.1 vs 1.7 ± 1 days; P = .02) were longer for revisional bariatric surgery versus primary bariatric surgery, respectively. Total weight loss was less in revisional bariatric surgery compared with primary bariatric surgery at 1 year (23 ± 10% vs 32 ± 9%; P < .001) and 2 years (21 ± 12.% vs 32 ± 10%; P < .001) of follow-up; however, no differences were detected in postoperative occurrences, emergency department visits, readmissions, reintervention and reoperation rates, and comorbidity resolution. ConclusionAlthough revisional bariatric surgery was associated with longer operation times, prolonged hospitalization, and lower weight loss than primary bariatric surgery, it was accomplished safely and led to substantial weight loss and comorbidity resolution. This information can guide patient counseling before revisional surgery for weight recurrence.

The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb

ObjectiveThe double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. MethodsA prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. ResultsA total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. ConclusionA high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.

Patient characteristics, surgical treatment, and outcomes in spinal gout: a systematic review of 315 cases.

To systematically investigate all published literature on spinal gout regarding location demographics, patient characteristics, treatment, and outcomes. We performed a systematic literature search of Medline and EMBASE from inception until April 15, 2023. Two investigators performed data extraction and quality assessment of location demographics and patient characteristics and outcomes of all article types describing spinal gout. A total of 214 articles (204 case reports and 10 case series) were included, encompassing 315 subjects with spinal gout (81% male, mean age 58.1years; range: 16-92). Most cases (36%) were between the age of 60-69years. We observed an increase in publications and cases from 1950 to the present. Most patients were from institutions in Asia (n = 119, 37.8%) and North America (n = 96, 30.5%). Reported symptoms frequently included back pain (75%), radiating pain to extremities (27.3%), and weakness in the extremities (26.3%). The lumbar spine was most often affected. Pharmacological treatment was described for 108 (34.2%) patients. Surgery was performed for 146 (46.3%) of patients, of which 4.8% had postoperative complications. Three patients (2%) required secondary surgery for recurrence. Published cases of spinal gout have increased over the last decades. Patient characteristics of spinal gout were similar to findings in systemic gout. Trends identified in patient characteristics and treatment outcomes may help guide patient management and improve our understanding of spinal gout.

Complication Pattern of Sacral Primary Tumor Resection: A Study on the Risk Factors of Surgical Site Infection and Bowel or Bladder Dysfunction and Their Associations with Length of Hospital Stay.

Retrospective open cohort study. The current study aimed to explore the pattern of complications after primary sacral tumor resection, to investigate the possible effect of several perioperative parameters on the development of complications, and to identify which complications are associated with the length of hospital stay (LOS). Primary sacral tumor (pST) resection is associated with a high complication rate. However, the number of studies on these complications and their effect on LOS is limited. The clinical data of 140 patients with pST surgeries and 106 subsequent patients with local recurrence surgeries in four subgroups (index surgery, local recurrence surgery, malignant, and benign tumor) were prospectively collected and analyzed. The prognostic value of several perioperative factors on the development of surgical site infection (SSI), bowel and bladder dysfunction (BBD), and LOS was investigated using the logistic and linear regression models. The overall complication rates were 61.2% after index surgeries and 50.9% after local recurrence surgeries. The most frequent complications were SSI, vegetative dysfunction, urinary tract infections, and neurological deterioration. Age >55 years, malignant tumors, and red blood cell transfusion had a predictive effect on the development of SSI in the logistic model (p<0.01, R2=0.43). Bilateral S2 or S3 resection commonly caused postoperative BBD (chi-square test=62.5, degrees of freedom=4, p<0.001). In the multiple linear regression model, wound dehiscence, BBD, systemic and urinary tract infection, cerebrospinal fluid leak, and neurologic deterioration were associated with a significantly long LOS (p<0.01, R2=0.62). Surgical resection of pSTs has a high complication rate. Its common complications are SSI and BBD, both of which can have a significant influence on global therapeutic outcome. Malignant tumor diagnosis, old age, and red blood cell transfusion can remarkably increase the risk of SSI. Further, the development of BBD is significantly associated with the number of resected sacral nerve roots. By decreasing perioperative complications, LOS can decrease significantly.

P20.14.B SYSTEMIC THERAPY FOR RECURRENT ADULT INTRACRANIAL AND SPINAL EPENDYMOMAS: A MONO-INSTITUTIONAL EXPERIENCE

Abstract BACKGROUND Ependymoma is a rare disease in adult patients (pts) and there is no standard systemic treatment in recurrent disease after surgery and radiotherapy. We reviewed our cases of confirmed intracranial and spinal ependymomas and described experience of pts treated with systemic therapies at disease recurrence. MATERIAL AND METHODS We retrospectively collected data of pts with histopathologically confirmed intracranial and spinal ependymomas from Veneto Institute of Oncology IOV in Padua, Italy from April 2018 to April 2023 and identified a subgroup of pts that received at least one line of systemic therapy at disease recurrence. All ependymomas were classified according to WHO 2016. As local protocol, brain and spinal MRI was performed every 2-3 months or when clinically indicated. RANO criteria were used to neuroradiological response. Primary endpoints were disease control rate and progression-free survival. RESULTS A total of 36 adult pts with ependymoma were identified, 18 males, median age at diagnosis 43. Tumor locations were spine (n=6), infratentorial (n=6), supratentorial (n=24). The majority were grade 3 (n=15), the others grade 2 (n=11) and grade 1 ependymoma (n=10).9 selected pts received at least one line of systemic treatments at disease recurrence (6 female, 3 male, median age at diagnosis 42 years). The majority were grade 3 (n=7), the others grade 2 (n=2). All 9 pts had undergone surgery and adjuvant radiotherapy. In this subgroup, the median time to recurrence from diagnosis was 12.4 months (range 3-32). At disease recurrence surgery was re-performed in 3 pts. Median number of lines of systemic therapies was 2, with a range from 1 to 6. TMZ alone in 4 pts with a DCR 40% and mPFS 4ms; TMZ+ cisplatin in 2 pts (DCR 50%, mPFS 4ms); TMZ+lapatinib in 3 pts (DCR 33%, mPFS 3.5ms); TMZ+bevacizumab in 1 pt (DCR 0%, mPFS 2ms); bevacizumab alone in 2 pts (DCR 0%, mPFS 2ms); bevacizumab+fotemustine in 1 pts (DCR 100%, mPFS 14ms), fotemustine alone in 2 pts (DCR 50%, mPFS 7.5ms); carboplatin 1 pts (DCR 0%, mPFS 2ms). At the data cut-off (April 2023), median overall survival from the date of diagnosis was 18.5 months (range 2-50). CONCLUSION The management of recurrent ependymoma in adults remains a therapeutic challenge. Our experience reflects heterogeneity regarding systemic treatments for patients with more aggressive ependymomas. Even if it was a small population, TMZ plus cisplatin ,fotemustine alone or in association with bevacizumab might represent promising treatments. However, other larger and prospective studies are needed.

Bariatric Surgeon Perspective on Revisional Bariatric Surgery (RBS) for Weight Recurrence.

Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons. Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS). Web-based survey of bariatric surgeons. A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options. One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively). This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.

Meme Koruyucu Cerrahide İntraoperatif Ultrason ve Frozen Patoloji Kullanımının Güvenli Cerrahi Sınır Üzerindeki Etkinliği

Background: Breast cancer is the most common cancer in women over the age of 40. The lifetime risk is around 12%. Today, breast cancer patients are diagnosed at an early stage thanks to screening programs, and thus mortality has decreased to around 25-30%. The positivity or closeness of surgical margins in breast conserving surgery varies between 5-60%. Negativity of surgical margins is very important to prevent future recurrent breast cancer, to pre-vent recurrent surgeries, and to prevent additional treatments. In this study, we aimed to investigate the efficacy of intraoperative ultrasonography and frozen section use in breast cancers treated with breast conserving surgery in obtaining safe surgical margins and in postoperative cosmetic terms. Materials and Methods: This study includes 150 patients diagnosed with breast cancer and treated with breast con-serving surgery in between January 2015 and January 2019. The presence of distant metastases and multifocal or centrally located tumor involvement in the breasts were investigated. The localization of the tumor was marked anatomically by preoperative ultrasonography in all patients. The operation was started 15 minutes after the injec-tion. The tumor was completely excised, leaving at least 1 cm of intact tissue around the tumor, including the skin, on the preoperatively marked area, including the underlying muscle fascia. Medial and superior borders were marked with string. This excised tissue block was examined with intraoperative ultrasonography. Results: The mean age of the patients was 48,3± 9.7 years. While the tumor was located in the right breast in 83 (55.3%) of the patients, it was located in the left breast in 67 (44.7%) patients. The tumor was located in the upper outer quadrant in 67 (44.7%) patients, in the upper inner quadrant in 53 (35.3%) patients, and in the lower outer quadrant in 30 (20%) patients. Axillary dissection was performed in 21 (14 %) of the patients because sentinel lymph node was positive. In histological typing, 141 (94 %) patients were ductal carcinoma and 9 (6 %) patients were lobular carcinoma. Conclusions: As a result of our study and literature review, we think that frozen examination together with intraope-rative ultrasonography is a simple, easily applicable and cosmetically good method to determine the safe surgical margin in breast conserving surgery.

A Program of Life-Style Modification Improved the Body Weight and Micronutrient Status in Obese Patients after Bariatric Surgery.

Bariatric surgery is an efficient approach to rapidly reduce morbid obesity and associated comorbidities. However, approximately one-fourth of patients experience weight and comorbidity recurrence, and both obesity and bariatric surgery can lead to micronutrient deficiencies. Implementing a structured program of lifestyle modification (PLM) might enhance weight loss and improve micronutrient status. A total of 121 severely obese patients underwent Roux-en-Y gastric bypass (RYGB). Among them, 71 adhered to a PLM involving dietary changes (low- and very-low-calorie Mediterranean diets) and physical exercises (aerobic and resistance training) both before and after surgery, while 50 patients followed a conventional protocol. Anthropometric measurements and serological parameter quantifications were conducted throughout the procedures. The obese study population, primarily female (76.9%), with an average age of 47.11 ± 9.68, and a body mass index (BMI) of 44.68 ± 5.08 kg/m2, underwent either RYGB with a PLM or a conventional procedure. Before surgery, the PLM group exhibited significant reductions in body weight (6.3%) and phosphoremia compared to the conventional protocol (0.78%). Post-RYGB, the PLM group demonstrated shortened in-hospital stays and further BMI reductions (-16.12 kg/m2) that persisted for up to 2 years. Furthermore, the PLM group experienced increased plasma vitamin D levels (14.79 ng/mL vs. 1.2 ng/mL) for up to 2 years, as well as elevated folic acid (1.52 vs. -0.29 ng/mL) and phosphorus (0.48 vs. 0.06 mg/dL) levels at 1 month and 1 year after intervention, respectively. Notably, these effects were independent of weight loss. Initiating a structured PLM from the early stages of patients' preparation for RYGB could enhance and extend the benefits of weight loss and positively impact micronutrient (vitamin D, phosphorus, and folic acid) status in obese patients.

Management of Medullary Thyroid Cancer: Patterns of Recurrence and Outcomes of Reoperative Surgery.

There remains uncertainty regarding the optimal extent of initial surgery and management of recurrent disease in medullary thyroid cancer (MTC). We aim to describe the patterns of disease recurrence and outcomes of the reoperative surgery in a cohort of consecutively treated patients at a specialized tertiary referral center. A retrospective cohort study of 235 surgically treated patients with MTC at a tertiary referral center was performed using prospectively collected data. In the study period 1986-2022, 235 patients underwent surgery for MTC. Of these, 45 (19%) patients had reoperative surgery for cervical nodal recurrence at a median (range) 2.1 (0.3-16) years following the index procedure. After a median follow-up of 4 years, 38 (84%) patients remain free of structural cervical recurrence, although 15 (33%) underwent 2 or more reoperative procedures. No long-term complications occurred after reoperative surgery. Local cervical recurrence was independently predicted by pathologically involved nodal status (OR 5.10, P = .01) and failure to achieve biochemical cure (OR 5.0, P = .009). Local recurrence did not adversely affect overall survival and was not associated with distant recurrence (HR 0.93, P = .83). Overall survival was independently predicted by high pathological grade (HR 10.0, P = .002) and the presence of metastatic disease at presentation (HR 8.27, P = 0018). Loco-regional recurrence in MTC does not impact overall survival, or the development of metastatic disease, demonstrating the safety of the staged approach to the clinically node-negative lateral neck. When recurrent disease is technically resectable, reoperative surgery can be undertaken with minimal morbidity in a specialized center and facilitates structural disease control.

Intramedullary nailing versus cemented plate for treating metastatic pathological fracture of the proximal humerus: a comparison study and literature review

BackgroundPathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus.MethodsThis retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications.ResultsAmong 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60–200) versus 500 (350–600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6–8) versus 6 (5–7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27–29) versus 27 (26.5–28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery.ConclusionsIntramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients.Level of evidence Level II.Trial registration statement Not applicable.

Laparoscopic sacrocolpopexy in the management of recurrent pelvic organ prolapse

ObjectivesWe set out to assess long-term anatomical and functional outcomes in women after laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse. MethodsAll women with a history of pelvic organ prolapse surgery operated between 2005 and 2022 were enrolled in this retrospective observational study. The indication for recurrent POP surgery was a symptomatic stage II and above pelvic organ prolapse. The data from objective urogynecologic examination and subjective patient assessment using validated questionnaires were collected. The last follow-up information was evaluated. The outcomes were compared with preoperative state using Student t-test and Wilcoxon test, p<0.05 was considered significant. Results39 women were enrolled in the study. The rate of perioperative complications was very low; no significant hemorrhage, ureteral damage or conversion to laparotomy were observed. The mean follow-up was 40 ± 26.8 months. The postoperative course was not complicated by bowel incarceration, pelvic infection or mesh exposure. We observed a statistically significant elevation of all POP-Q points and decrease in all mean scores of PFDI, PFIQ, Wexner and VAS prolapse bother postoperatively. Improvement in stress urinary incontinence, anal incontinence and constipation was found. ConclusionsLaparoscopic sacrocolpopexy for recurrent pelvic organ prolapse is a safe and effective surgery regardless of the type of the original repair performed. It provides good subjective and anatomical outcomes with a lasting effect on the quality of life in a long-term follow-up.

Re-operative surgery for differentiated thyroid cancer: A single institutional experience of 182 cases

IntroductionRe-operative thyroid surgery (RTS) is performed in patients of differentiated thyroid cancer (DTC) with residual or recurrent disease. However, there is a paucity of literature discussing experience and technique of RTS. This study aims to address this gap by providing a comprehensive review of RTS for DTC, utilizing experiences from a dedicated complex thyroid surgical oncology program at the apex hospital in a developing country. MethodsA retrospective analysis was conducted using data from the Department of Surgical Oncology's thyroid cancer database. The study period spanned from 2006 to 2022. Clinical presentation, prior surgical history, operative details of RTS, and post-operative outcomes were assessed. Descriptive analysis was performed. ResultsDuring the study period, a total of 182 patients underwent re-operative thyroid surgery (RTS). The primary surgeries performed prior to RTS included near-total or total thyroidectomy in most cases (69.2%), and approximately half of the patients (48.4%) had prior neck node interventions. The RTS procedures consisted of completion total thyroidectomy in 30.8% of cases and surgery for thyroid bed recurrence in 9.9% of cases, while central node dissection was performed in 46.2% of patients and unilateral or bilateral template neck dissection was performed in 41.8% of cases. Extended resections were required in 9.3% of patients. Post-operative complications included permanent hypoparathyroidism (2.7%) and unilateral recurrent laryngeal nerve palsy (1.6%). ConclusionsRTS is a complex procedure with high rates of post-operative morbidity reported in literature. Optimal outcomes require a multidisciplinary approach, thorough assessment, and skilled surgeons.

ThTP2.11 Three-year follow up outcomes in mesh-augmented vs sutured cruroplasty in giant hiatal hernia repair

Abstract Aims There is no consensus for indications on mesh-augmentation of crural repair in hiatus hernia. We evaluated outcomes following mesh-augmented versus suture repair of giant hiatus hernia. Methods Giant hiatus hernia was defined as a hernia containing at least 30% of the stomach in the thorax. We undertook a retrospective analysis of records for patients undergoing surgical repair of hiatus hernia in a tertiary centre between 2016 and 2019, with a minimum follow up of three years. Patients were identified using clinical coding. Pre-operative investigations (OGD, barium swallow, CT) and operative findings were used to identify those patients with giant hiatus hernias. Outcomes assessed included morbidity, recurrence and revisional surgery. Results 58 patients of median age 72 (27-90) underwent repair of a giant hiatus hernia. 56 (97%) were performed laparoscopically (1 conversion, 1 open). All were primary procedures, 50 elective and 8 emergency. 20 had mesh-augmented suture repair (19 BIO-A, 1 Permacol) and 38 had primary suture repair alone. 26 (44.8%) had additional fundoplication. By three years post-surgery 14/58 (24%) recurrent hiatus hernias were identified on further investigation, similar in both groups (5/20 vs 9/38). Symptomatic revisional surgery was undertaken in 2/20 (10%) mesh-augmented and 2/38 (5%) suture only repairs. 30-day mortality was 0%. Morbidity (Clavien-Dindo 3+) was recorded in 5 patients (8.6%). Conclusion Giant hiatal hernia repair complication and recurrence rates were comparable to published studies. Those patients with recurrence following mesh-augmented repair were more likely to require revision surgery. However mesh may be used in cruroplasty for perceived weaker or wider crura.

Outcomes of recurrent incisional hernia repair by open and laparoscopic approaches: a propensity score-matched comparison.

Recurrent incisional hernias are challenging, and their surgical outcomes have not been well studied. We aimed to analyze the outcomes of recurrent incisional hernia repair in a propensity score-matched cohort study on laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) versus open sublay repair. All consecutive patients who had undergone open sublay repair and lap. IPOM of recurrent incisional hernia between January 2015 and December 2021 at a tertiary hernia center was identified. One-to-one propensity score matching was used to achieve a balanced exposure groups at baseline. Of 255 patients, 85/95 with open sublay repair were matched to 85/160 with lap. IPOM. Before matching, the open sublay group had significantly larger hernia defects (6.3cm vs. 5.0cm) than the lap. IPOM group. Other major baseline imbalances were also found in body mass index (BMI), obesity and European Hernia Society (EHS) width classification. The pre-match results showed that the lap. IPOM group had significantly shorter operative time (median 75 vs. 95min) and shorter postoperative hospital stay (median 8 vs. 11days) compared with the open sublay group. Wound infection (8.4% vs. 1.9%) and hematoma (5.3% vs. 0.6%) occurred more frequently after open sublay repair. After matching, baseline characteristics were well balanced. The recurrence rate and incidence of complications were comparable between the two groups. However, the post-match analysis still showed that lap. IPOM was associated with decreased length of postoperative stay. The outcomes of recurrent incisional hernia surgery after lap. IPOM and open sublay repair appear similar, except that the former had shorter length of postoperative stay. However, the poor outcomes were more likely associated with the unfavorable risk profiles, such as larger defect size, rather than the procedure technique itself.