Selection Of Patients For Surgery Research Articles

Recurrence rate after radical prostatectomy following primary staging of high-risk prostate cancer with 68Ga-PSMA PET/CT

Background Accurate primary staging is one of the most important issues for initial management of prostate cancer (PCa) patients to perform an optimal selection of patients for curative intended treatment. 68Ga-Prostate-Specific-Membrane-Antigen (PSMA) PET/CT was found superior to conventional imaging both for detection of recurrence after curative intended treatment and for primary staging. We studied the recurrence rate after radical prostatectomy in high-risk PCa patients primary staged with 68Ga-PSMA PET/CT compared with conventional imaging. Material and methods The study included 247 D’Amico high-risk PCa patients treated with radical prostatectomy (RP) after primary staging with 68Ga-PSMA PET/CT and a reference group of 137 high-risk patients with RP after conventional imaging (99mTc bone scintigraphy and CT). Recurrence rates were assessed by Cox regression and Kaplan-Meier analysis. Results The 5-year recurrence-free survival rate was 71.1% in the 68Ga-PSMA PET/CT cohort compared with 56.4% in the conventional imaging cohort. Primary staging by 68Ga-PSMA PET/CT reduced biochemical recurrence (BCR) risk by 42% (HR = 0.58 (0.41–0.83), p = .004). Conclusion The present data could indicate a lower recurrence rate after RP following primary staging with 68Ga-PSMA PET/CT compared to conventional imaging, likely due to improved selection of patients for surgery.

Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study

IntroductionOptimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision. MethodsA prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed. ResultsOf 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea. ConclusionsAfter MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

Five decades of progress in surgical oncology: Tumors of the lung and esophagus.

During the past 50 years, there has been a remarkable transformation in the management of lung and esophageal cancers. Improved methods of diagnosis, better staging and patient selection for surgery, the advent of minimally invasive approaches to resection, decreasing operative mortality, greater insights into tumor biology, and the development of effective multimodality therapies and precision medicine have contributed to this transformation. Progress has been most notable in lung cancer.

Advances in the management of liver and biliary tumors.

Over the past 50 years, the management of liver and biliary tumors has evolved significantly. Initially considered highly morbid and lethal, resection is now the treatment of choice for a significant proportion of patients with malignant and benign hepatobiliary disease. Improved operative/anesthetic techniques, use of parenchymal-sparing approaches, better patient selection for surgery, effective liver-directed therapies, and new insights into tumor biology are significant contributors to our transformed approach to hepatobiliary neoplasms.

Clinical Profile and Management of Chronic Pancreatitis in Tertiary Care Centre

Background Constant inflammation and irreversible pancreatic tissue destruction are hallmarks of the disease of chronic pancreatitis (CP), which results in the decrease of both exocrine and endocrine function over time. It is a multifactorial disease, with a wide range of symptoms and geographic variation. Aim Aim of this study is to study clinical profile and management of CP with respect to demography, clinical findings, lab parameters, imaging investigations and management modalities. Methods A cross-sectional observational study was conducted which included the patients admitted to the tertiary care center presenting with the clinical diagnosis of CP. The study was conducted over a period of 2-years from November 2019 to October 2021. A total sample size of 71 patients was included. Results In the study, it was observed that the majority of patients were in the age group of 51-60-years (47.89%) followed by 41-50-years (21.12%) mean age ranges from 56.54±12.63-years. The majority of patients were male (76.06%) and females were 23.94%. The distribution of patients according to aetiology showed that the majority of patients had aetiology of alcoholism (43.66%) followed by idiopathic (29.57%) Gall/Biliary stones (21.12%) and post-operative (5.63%). Majority of patients presented with pain in the abdomen (85.92%). The distribution of patients according to ultrasound sonography test (USG) findings showed that majority of patients shows pancreatic calcification (54.93%) followed by pancreatic pseudocyst (32.39%) and gall stones (19.72%). The distribution of patients according to computed tomography (CT) findings showed that majority of patients shows pancreatic calcification (70.42%). In the present study, it was observed that majority of patients were managed conservatively (43.66%) followed by cystogastrostomy (18.31%) and cystojejunostomy (8.45%). Endoscopic retrograde cholangiopancreatography (ERCP) was done among 14 (19.72%) patients. Lateral pancreaticojejunostomy was done in 6 (8.45%) patients and pancreaticoduodenectomy (Classical Whipple’s) was done in 4 patients (5.63%). The distribution of patients according to pain relief by various management showed that majority of getting relief from pain by surgery (69.23%) followed by ERCP (35.71%) and the least by conservative/analgesics (6.45%). Conclusion Chronic pancreatitis is progressive inflammatory disease. Alcoholic pancreatitis being most common etiology. Pain is most common presenting symptom. CT scan abdomen most useful in confirming diagnosis in our set up. Pseudocyst being common complication seen. Surgery gives relief of pain in most of the cases. The key to a better outcome is making the right decisions in terms of diagnosis, patient selection for surgery, and surgical type.

Evaluation of the Effectiveness of the Tap Test by Combining the Use of Functional Gait Assessment and Global Rating of Change.

BackgroundAlthough the tap test for patients with suspected idiopathic normal pressure hydrocephalus (iNPH) is still often performed as part of the preoperative evaluation, it is true that some studies have reported the limitations of the tap test, claiming that it does not provide the additional information for appropriate patient selection for surgery. We aimed to determine whether a better method of pre- and post-tap test assessment could lead to appropriate patient selection for shunting.MethodsWe performed the tap test as part of the preoperative evaluation in all 40 patients who underwent lumboperitoneal shunt surgery for iNPH from April 2021 to September 2021. We retrospectively analyzed the patient data. We examined whether a comprehensive evaluation of the effect of the tap test using the Functional Gait Assessment (FGA) and Global Rating of Change (GRC) scales would identify a wider range of patients who would benefit from shunt surgery than the 3-m Timed Up and Go test (TUG) alone.ResultsAssuming a prevalence of 1% for iNPH, the TUG had a sensitivity of 0.23, specificity of 0.71, positive likelihood ratio of 0.79, and negative likelihood ratio of 1.09. When improvement in either the FGA or the GRC was used as a criterion for the validity of the tap test, the sensitivity was 0.88, specificity was 0.17, positive likelihood ratio was 1.06, and negative likelihood ratio was 0.71.ConclusionImprovement in either the FGA or the GRC is a more sensitive criterion for the effectiveness of the tap test for the gait aspect than the TUG. Since the negative likelihood ratio is lower than that for the TUG alone, it is more appropriate to exclude patients with neither FGA nor GRC improvement from surgical indications than to exclude surgical indications based on a negative TUG.

Progression of aortic root based on long-term imaging studies after acute type A dissection repair.

To determine the progression of aortic root in acute type A aortic dissection (ATAAD) patients after aortic root repair (ARr) or replacement (ARR) based on long-term follow-up imaging studies. From 1996 to 2019, 732 patients had ATAAD repair at our institution. Six hundred and seven of these patients had either ARr, (n = 383) or ARR (n = 224). Eighty-one patients were excluded due to a lack of postoperative imaging. Three hundred and thirty-two patients were included in the repair group and 194 patients in the replacement group for long-term follow-up imaging study. Compared to the ARR group, the ARr group was significantly older (60 years vs. 55 years) and had more patients with hypertension (79% vs. 63%) but less male patients (63% vs. 79%) and connective tissue disorder (1.8% vs 8%). The ARr group had more zone two arch replacement (22% vs. 11%), similar HCA time (35 min vs. 31 min), shorter cardiopulmonary bypass time (203 min vs. 266 min), aortic cross-clamp time (128 min vs. 214 min), and fewer concomitant coronary artery bypass (3.9% vs. 8.9%). The root growth rate over 12 years was similar between the repair and replacement group (0.20 mm/year vs. 0.18 mm/year, p = .75). Both the repair and replacement group had similar 15-year cumulative incidence of reoperation (6.9% vs. 5.9%; p = .67), operative mortality (7.8% vs. 8.5%; p = .78), and 15-year survival (51% vs. 52%; p = .40). There was minimal growth of the aortic root after root repair or replacement for ATAAD patients. Both aortic root repair and replacement were acceptable techniques for ATAAD surgery in select patients.

Comparison of Craniotomy and Stereotactic Aspiration Plus Thrombolysis in Isolated Capsulo-Ganglionic Hematoma

Published trials and meta-analyses have suggested the role of surgery in select patients of hypertensive intracerebral hematoma. This study compares two methods of hematoma aspiration, craniotomy, and stereotactic aspiration. We conducted retrospective analyses of patients who underwent surgery for capsule-ganglionic hematoma during Jan-2015-Dec-2019. Surgical, intensive-care parameters, and neurological outcomes were compared. Patients operated for Capsule-Ganglionic hypertensive hematomas, Glasgow Coma Scale (GCS) 5-12, hematoma volume ≥30 ml, no concomitant IVH, age <80 years were included. A total of 173 patients were included (90 craniotomy and 83 stereotactic aspiration groups). Both groups were equivalent in preoperative parameters (P > 0.5). There were no significant differences in residual hematoma volumes, surgical site infections/Meningitis, and chances of re-bleed between the two groups (P > 0.05). The number of days on ventilation, ICU-stay, and hospital-stay were higher in craniotomy group (P < 0.001). Mean Modified Ranking Score (MRS) was lower (P 0.01) in the stereotactic aspiration group. A higher number of patients in the stereotactic aspiration group achieved good MRS (0-2) (P 0.02). Overall case-fatality rate was 38/173 (21.96%) (craniotomy - 24/90 (26.66%), stereotactic aspiration - 14/83 (16.86%), P 0.12). In left-side hematomas, mean MRS was not different between both methods, whereas it differed in the right-side hematomas. On step-wise logistic regression analysis, predicting parameters for the poor outcome (MRS 3-6) were GCS 5-8 (Odds Ratio (OR) 2.38), Left-side (OR 1.75), and craniotomy as a method of evacuation (OR 1.70). Stereotactic aspiration of the hematoma has the superior edge over craniotomy. Neurological and care parameters are significantly better with stereotactic aspiration. Its safety and surgical performance parallel craniotomy.

339 Influence of SEEG on Temporal Lobectomy

INTRODUCTION: Seizure outcomes after surgical resection in temporal lobe epilepsy (TLE) are historically better in the presence of a discrete MRI lesion, as the surgical hypothesis is better informed by imaging. The role of intracranial monitoring via stereotactic electroencephalography vs. proceeding directly to surgery in this patient population remains under debate. METHODS: SEEG usage trends were investigated for 391 consecutive patients who had temporal lobectomy performed from 2015 to 2020. Correlation with Engel scores at 1 year post-op was performed using chi-square for 259 patients in whom this data was available. RESULTS: Sparing of mesial structures was more common in patients who had SEEG (35% vs 20%, p &lt; 0.01). There was a nonsignificant trend towards better outcomes in patients who did not have SEEG (63.5% Engel 1 vs 50.5%, p &lt; 0.55). MRI abnormalities were significantly more prevalent in the cohort that underwent SEEG (92% vs. 58%, p &lt; 0.001), and there was no significant association between the presence of MRI abnormality and outcome (p = 0.59). CONCLUSION: We found no statistically significant difference in seizure freedom in patients who undergo temporal lobectomy with SEEG in the presurgical workup. This likely results from SEEG being used when the surgical hypothesis is difficult to formulate, reflected by the increased prevalence of distinct imaging abnormalities in the non-SEEG cohort. Thus it seems that the use of SEEG helps close the gap in outcomes for patients with non-lesional temporal lobe epilepsy. There was no difference in outcomes associated with the decision to spare mesial structures, indicating this effect likely stems from patient selection for surgery. Our future work will look into the connection between SEEG and volumes of surgical resection.

A penetrating thoracoabdominal injury with arrow head: a case report

Penetrating injuries to the chest present a frequent and challenging problem. The majority of these injuries can be managed non-operatively. The selection of patients for operation or observation can be made by clinical examination and appropriate investigations. A 17 years old male patient presented with an arrow inserted in his chest wall 5 cm. below right nipple. The patient was stable hemodynamically with no signs and symptoms of pneumothorax. Imaging of chest and abdomen, followed by laparotomy and removal of the arrow head from left lobe of liver performed.

GATA6 Expression as a predictor of response to perioperative chemotherapy in resectable pancreatic adenocarcinoma: A multicenter Canadian phase II study (NeoPancONE).

TPS638 Background: Prospective studies of the benefit of neoadjuvant chemotherapy in resectable pancreatic adenocarcinoma (PDAC) have been reported. The ideal peri-operative regimen is yet to be determined. Adjuvant FOLFIRINOX (mFFX) in resected PDAC has been proven to improve overall survival (OS) relative to adjuvant gemcitabine. An accepted perioperative approach involves delivering the majority of chemotherapy (6-8 cycles) in the pre-operative setting, while the remainder (of 12 cycles) is administered post-operatively. This pre-operative treatment period may allow for chemosensitivity assessment, and better patient selection for surgery, thereby improving R0 resection rates and reducing the frequency of early post-operative recurrence. Data from the COMPASS trial (NCT02750657) has shown that shown that low levels of the transcription factor GATA6 expression is a putative surrogate for the RNA Moffit signature and predictive of a chemoresistant phenotype in advanced PDAC. NeoPancONE will evaluate clinical outcomes and molecular biomarkers including GATA6 and radiomic biomarkers in pts with resectable PDAC treated with perioperative mFFX. Methods: NeoPancONE is a Phase 2, open-label, single arm study in pts with resectable PDAC. Tissue and serum are collected for biomarker testing, including GATA6 by FISH and IHC (1) with expression levels measured by RNAseq, and longitudinal ctDNA analysis. Pts with histologically confirmed, resectable PDAC and ECOG PS 0-1 will be recruited over 2.5 years. Resectability will be determined by central review as per NCCN guidelines. The primary objective is to evaluate disease-free survival in resectable PDAC treated with peri-operative mFFX according to baseline tumor GATA6 expression level. The ratio of GATA6-high to low is expected to be approximately 4:1[1]. Assuming 1-year disease-free survival of 65% in the GATA6-high, compared to 34% in the GATA6-low cohort, this corresponds to a hazard ratio of 2.5. With 80% power and a 5% 2-sided significance level, a total of 84 patients will be enrolled with 67 events expected in the GATA6 high cohort and 17 in GATA6 low. Participants will receive up to 6 cycles of neoadjuvant mFFX. After neoadjuvant chemotherapy, definitive surgical resection will proceed as deemed appropriate by a hepatobiliary surgeon. Post-operatively, pts will receive up to 6 cycles of adjuvant chemotherapy. Secondary objectives include determination of overall response rate, incidence of R0 resection, OS, Moffit gene expression profiling (RNAseq), ctDNA, and radiomic signatures to predict outcomes. Enrolment for NeoPancONE began in October 2020 and is being conducted at 8 sites across Canada. To date, 23 pts have been recruited. The study duration will be five years. Reference: O’Kane G M et al. Clin Can Res Sep 2020. Clinical trial information: NCT04472910.

Surgical Outcomes for Early-Stage Non-Small Cell Lung Cancer at Facilities With Stereotactic Body Radiation Therapy Programs

<h3>Purpose/Objective(s)</h3> Patients undergoing surgery for early-stage non-small cell lung cancer (NSCLC) may be at high-risk for post-operative mortality. Access to stereotactic body radiation therapy (SBRT), a less invasive alternative, may facilitate more appropriate patient selection for surgery. <h3>Materials/Methods</h3> An analysis of all patients with early-stage NSCLC reported to the National Cancer Database between 2004-2015 was performed. Post-operative mortality rates were derived using vital status data. Utilization of SBRT was defined by each facility's SBRT Experience in years and SBRT-to-Surgery Volume Ratios, defined by quartiles. Multivariable logistic regression with backward elimination was used to test for the associations between facility-level SBRT utilization and post-operative mortality. Interaction testing of independent covariates was performed to assess the effect of SBRT utilization across subgroups. <h3>Results</h3> The study cohort consisted of 202,542 patients who underwent surgical resection of clinical stage T1-T2 N0 M0 NSCLC between 2004-2015. The 90-day post-operative mortality rate declined significantly during the study period from 4.6% to 2.6% (p < 0.001). During this period, the proportion of facilities that utilized SBRT increased from 4.6% to 77.5% (p < 0.001) and the proportion of patients treated with SBRT increased significantly from 0.7% to 15.4% (p < 0.001). On multivariable analysis, lower 90-day post-operative mortality rates were observed among patients who underwent resection at facilities with greater than six years of SBRT Experience (OR 0.84, CI 0.76-0.94, p = 0.003) and SBRT-to-Surgery Volume Ratios above 17% (OR 0.85, CI 0.79-0.92, p < 0.001). Additional covariates associated with 90-day mortality included higher surgical volume, geographic region, year of diagnosis, age, sex, race, insurance status, facility type, Charlson-Deyo score, clinical T stage, histology, anatomic location, surgery type, and prior malignancy. Interaction testing between these covariates was negative, demonstrating that findings were consistent across subgroups. <h3>Conclusion</h3> Patients who underwent surgical resection for early-stage NSCLC at facilities with higher SBRT Experience and SBRT-to-Surgery Volume Ratios had lower rates of post-operative mortality. These findings suggest that the availability of SBRT may improve allocation of patients to surgery or SBRT, particularly for higher-risk patients. The observation of higher post-operative mortality rates at facilities without an SBRT program merits further investigation.

Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome

Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.

Impact of Intraoperative Gravity-Dependent Atelectasis Following Laparo scopic Liver Resection Performed in the Lateral Position

Laparoscopic liver resection (LLR) is currently an acceptable approach to liver surgery in select patients. The correlation between the intraoperative position and the presence of gravity-dependent atelectasis (GDA) has been well discussed. However, LLR is performed in the left half lateral position, and the relationship between this position and the presence of GDA remains unclear. We evaluated the extent to which the intraoperative left half lateral position affects the presence of GDA. Furthermore, univariate and multivariate analyses were performed to identify potential risk factors for postoperative complications after LLR with a special emphasis on the presence of GDA by comparing various patient-, liver- and surgeryrelated factors in a retrospective cohort. We retrospectively evaluated 129 patients who underwent LLR in the left half lateral position at the Saitama Cancer Center in Saitama, Japan, between March 2011 and July 2020. The frequency and duration of GDA were investigated. We divided the cohort into groups with GDA and without GDA based on a cutoff value (≥ 5 days, n = 61 and < 5 days, n = 68, respectively). Using multivariate analysis, the duration of GDA and several risk factors for postoperative complications after LLR were independently assessed. Postoperative GDA was observed in 61 patients (47%) and lasted for 1 to 8 days in these patients. The mean duration of GDA was 4.3 days. Multivariate logistic regression analysis revealed that a GDA duration of 5 days or more (odds ratio [OR], 2.03; p = 0.001) and an operating time > 388 minutes (OR, 5.31; p < 0.001) were independent risk factors for postoperative complications after LLR. The incidence and duration of postoperative GDA are considered useful predictors of postoperative complications, and these predictors should be assessed to improve the short-term outcomes of patients undergoing LLR.

Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome

Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.

O-L08 Prognostic value of body morphometrics in patients undergoing surgery for hilar cholangiocarcinoma

Abstract Background Hilar cholangiocarcinoma is an aggressive cancer with poor prognosis. Complex pre-operative workup is required prior to major surgery that frequently involves an extended hepatectomy with biliary reconstruction and is associated with high levels of post-operative morbidity and mortality. Tools to predict overall and disease-specific outcome are required to better tailor pre-habilitation interventions and selection of patients for surgery. Here we investigate whether body morphometrics are associated with disease-free and overall survival. Methods Consecutive patients undergoing resection of hilar cholangiocarcinoma were identified within a prospectively maintained database in a single institution. The CoreSlicer web-based app was used to calculate body morphometrics at the L3 vertebral level (muscle, visceral and subcutaneous fat areas) from portal-phase CT images. Median cut-offs defined patient groups and height-normalised morphometric values were compared at diagnostic and subsequent pre-operative imaging. Multivariate analysis was used to identify relationships between body morphometrics at time of diagnosis, changes in body morphometrics in the pre-operative period and outcome. Results Body morphometrics were assessed in 88 patients at the time of diagnosis. Of these patients, 53 underwent re-staging enabling an assessment of change in body morphometrics during the pre-operative period. Men displayed significantly higher muscle area, visceral fat and lower subcutaneous fat than women. High visceral fat area at diagnosis was an independent predictor of reduced overall survival (HR 1.81, 95% CI 1.1-3.3, P = 0.03), whilst loss of skeletal muscle area during the pre-operative period was an independent predictor of reduced disease-free survival (HR 2.90, 95% CI 1.0-8.8, P = 0.05). Patients with higher visceral fat at diagnosis also appear at increased risk of post-hepatectomy liver failure (PHLF) and experience significantly higher 30-day mortality than those without elevated visceral fat. Conclusions The presented results identify potential value in assessing body morphometrics as a prognostic tool in patients undergoing surgery for hilar cholangiocarcinoma. External validation of these findings in larger patient cohorts will help to determine whether this can be utilised to guide pre-habilitation interventions and appropriately select patients for surgery.

Seizure Outcome After Surgery for MRI-Diagnosed Focal Cortical Dysplasia: A Systematic Review and Meta-analysis.

Focal cortical dysplasia (FCD) has been associated with poorer postsurgical seizure outcomes compared to other pathologies. FCD surgical series have been assembled on the basis of a histologic diagnosis, including patients with abnormal and normal preoperative MRI. However, in clinical workflow, patient selection for surgery is based on preoperative findings, including MRI. We performed a systematic review and meta-analysis of the literature to determine the rate and predictors of favorable seizure outcome after surgery for MRI-detected FCD. We devised our study protocol in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered the protocol with PROSPERO. We searched MEDLINE, EMBASE, and Web of Science for studies of patients followed up for ≥12 months after resective surgery for drug-resistant epilepsy with MRI-detected FCD. Random-effects meta-analysis was used to calculate the proportion of patients attaining a favorable outcome, defined as Engel class I, International League Against Epilepsy class 1 to 2, or seizure-free status. Meta-regression was performed to investigate sources of heterogeneity. Our search identified 3,745 references. Of these, 35 studies (total of 1,353 patients) were included. Most studies (89%) followed up patients for ≥24 months after surgery. The overall postsurgical favorable outcome rate was 70% (95% confidence interval [CI] 64-75). There was high interstudy heterogeneity. Favorable outcome was associated with complete resection of the FCD lesion (risk ratio [RR] 2.42 [95% confidence interval (CI) 1.55-3.76], p < 0.001) and location of the FCD lesion in the temporal lobe (RR 1.38 [95% CI 1.07-1.79], p = 0.013) but not lesion extent, intracranial EEG use, or FCD histologic type. The number of FCD histologic types included in the same study accounted for 7.6% of the observed heterogeneity. Seventy percent of patients with drug-resistant epilepsy and MRI features of FCD attain a favorable seizure outcome after resective surgery. Our findings can be incorporated into routine preoperative counseling and reinforce the importance of completely resecting the MRI-detected FCD when safe and feasible.

Open versus minimally invasive small bowel resection for Crohn's disease: a NSQIP retrospective review and analysis.

Many patients with Crohn's Disease will require surgical resection. While many studies have described outcomes following ileocecectomy, few have evaluated surgical resection of other portions of small bowel. We sought to compare open and minimally invasive surgery (MIS) approaches for small bowel resection excluding ileocecectomy of patients with Crohn's Disease using the National Surgical Quality Improvement Program (NSQIP) database. The NSQIP database was queried for patients with Crohn's disease or complications related to Crohn's disease who underwent segmental small bowel resection utilizing open or minimally invasive approaches between 2012 and 2018. Patients requiring ileocecectomy or diagnosed with ascites, disseminated cancer, pre-operative sepsis, ASA class 5, and patients requiring mechanical ventilation were excluded. The association of pre-operative variables including patient demographic information and comorbidities with surgical approach were examined using Fishers exact test. Intraoperative, and 30-day post-operative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. After exclusions, we found 1697 patients with Crohn's disease who underwent segmental small bowel resection, 1252 of whom underwent open surgery and 445 of whom underwent MIS. After adjusting for possible confounders with multivariable analysis, patients who underwent MIS had a lower incidence of wound events (surgical site, organ space, or deep wound infection, or dehiscence), post-operative bleeding, need for return to the operating room, and shorter total hospital length of stay despite longer operative times compared with open surgery. This retrospective review of NSQIP shows that minimally invasive small bowel resection is associated with equivalent or improved morbidity over open surgery in select patients with small bowel Crohn's Disease. We show that in select patients minimally invasive small bowel resection can be safe and performed for patients with isolated small bowel Crohn's disease.

Surgical Outcomes for Early Stage Non-small Cell Lung Cancer at Facilities With Stereotactic Body Radiation Therapy Programs

Patients undergoing surgery for early stage non-small cell lung cancer (NSCLC) may be at high risk for postoperative mortality. Access to stereotactic body radiation therapy (SBRT) may facilitate more appropriate patient selection for surgery. Is postoperative mortality associated with early stage NSCLC lower at facilities with higher use of SBRT? Patients with early stage NSCLC reported to the National Cancer Database between 2004 and 2015 were included. Use of SBRT was defined by each facility's SBRT experience (in years) and SBRT to surgery volume ratios. Multivariate logistic regression was used to test for the associations between SBRT use and postoperative mortality. The study cohort consisted of 202,542 patients who underwent surgical resection of cT1-T2N0M0 NSCLC tumors. The 90-day postoperative mortality rate declined during the study period from 4.6%to 2.6%(P< .001), the proportion of facilities that used SBRT increased from 4.6%to 77.5%(P< .001), and the proportion of patients treated with SBRT increased from 0.7%to 15.4%(P< .001). On multivariate analysis, lower 90-day postoperative mortality rates were observed at facilities with > 6 years of SBRT experience (OR, 0.84; 95% CI, 0.76-0.94; P= .003) and SBRT to surgery volume ratios of more than 17%(OR, 0.85; 95% CI, 0.79-0.92; P< .001). Ninety-day mortality also was associated with surgical volume, region, year, age, sex, and race, among other covariates. Interaction testing between these covariates showed negative results. Patients who underwent resection for early stage NSCLC at facilities with higher SBRT use showed lower rates of postoperative mortality. These findings suggest that the availability and use of SBRT may improve the selection of patients for surgery who are predicted to be at high risk of postoperative mortality.

Diffusion tensor imaging in cubital tunnel syndrome

Cubital tunnel syndrome (CuTS) is the 2nd most common compressive neuropathy. To improve both diagnosis and the selection of patients for surgery, there is a pressing need to develop a reliable and objective test of ulnar nerve ‘health’. Diffusion tensor imaging (DTI) characterises tissue microstructure and may identify differences in the normal ulnar from those affected by CuTS. The aim of this study was to compare the DTI metrics from the ulnar nerves of healthy (asymptomatic) adults and patients with CuTS awaiting surgery. DTI was acquired at 3.0 T using single-shot echo-planar imaging (55 axial slices, 3 mm thick, 1.5 mm2 in-plane) with 30 diffusion sensitising gradient directions, a b-value of 800 s/mm2 and 4 signal averages. The sequence was repeated with the phase-encoding direction reversed. Data were combined and corrected using the FMRIB Software Library (FSL) and reconstructed using generalized q-sampling imaging in DSI Studio. Throughout the length of the ulnar nerve, the fractional anisotropy (FA), quantitative anisotropy (QA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) were extracted, then compared using mixed-effects linear regression. Thirteen healthy controls (8 males, 5 females) and 8 patients with CuTS (6 males, 2 females) completed the study. Throughout the length of the ulnar nerve, diffusion was more isotropic in patients with CuTS. Overall, patients with CuTS had a 6% lower FA than controls, with the largest difference observed proximal to the cubital tunnel (mean difference 0.087 [95% CI 0.035, 0.141]). Patients with CuTS also had a higher RD than controls, with the largest disparity observed within the forearm (mean difference 0.252 × 10–4 mm2/s [95% CI 0.085 × 10–4, 0.419 × 10–4]). There were no significant differences between patients and controls in QA, MD or AD. Throughout the length of the ulnar nerve, the fractional anisotropy and radial diffusivity in patients with CuTS are different to healthy controls. These findings suggest that DTI may provide an objective assessment of the ulnar nerve and potentially, improve the management of CuTS.