Time Of Primary Surgery Research Articles

PWE-284 Signet ring colorectal carcinoma (SRCC): do we need to improve the treatment algorithm?

Introduction SRCC is an aggressive variant affecting younger population and has poorer prognosis. The literature explaining the biology as well as the optimum treatment algorithm of this particular variant is scarce due to its low incidence. Here, we present our experience about this peculiar variant from a tertiary cancer centre from India (Tata Memorial Centre, Mumbai). Method It’s a retrospective study (2011–2014) of all patients diagnosed with SRCC with department of gastro-intestinal oncology. SRCC was defined as per WHO criteria (adenocarcinoma with more than 50% of signet-ring cells). Peritoneal metastases or recurrences constituted peritoneal deposits, malignant ascites, omental deposits, ovarian deposits. SPSS-20 was used for statistical calculation. Results 170 consecutive patients with SRCC were diagnosed. It constituted 11.4% of all colorectal cases (170/1487). Median Age of the cohort was 41 years. Male to female ratio was 1.8:1. Most common location was recto-sigmoid area (Rectum: 41.2% and Sigmoid: 13.5%). Majority patients presented in stage III (51.8%) and stage IV (39.4%). Most of the stage IV patients had isolated peritoneal metastases (58/67, 86.5%). Colonic tumours, as compared to rectal tumours had higher incidence of peritoneal metastases (83.3% v/s 91.4%, p = 0.074) as well as isolated peritoneal recurrences (20.5% v/s 37.5%, p = 0.062). Most patients had high nodal burden (pN2: 57.9%). Curative therapy was feasible only in 56.47% (79/170) patients. 36.7% patients recurred after curative surgery. Amongst them 65.5% patients had isolated peritoneal recurrences. Amongst rectal cases, pathological complete response after NACTRT was seen in 21.6% (8/37) patients. Circumferential resection margin (CRM) was involved in 17.9% (7/39) patients. Median follow up was 17.4 months. Median relapse free survival (RFS) and overall survival (OS) of the cohort were 14.9 and 18.13 months respectively. OS of peritoneal and non-peritoneal metastases were equivalent (16 v/s 13months; p = 0.729). CRM involvement was associated with poorer RFS (15 months v/s 37.2 months; p = 0.060) and OS (19.9 months v/s 41.5 months; p = 0.018). Colonic primaries were associated with poorer OS than rectal tumours after curative resection (32.298 months v/s 40.089 months, p = 0.058) and RFS (24.74 months v/s 34.02 months; p = 0.048). Conclusion SRCC affects young patients and has predilection for peritoneal dissemination. More aggressive and/or extended chemotherapy schedules as well as prophylactic HIPEC at the time of primary surgery, especially for colonic tumours, should be attempted in a randomised control trial setting in order to improve dismal survival in these patients. Disclosure of interest None Declared.

PTH-335 Permanent stoma rates following elective resection of rectal cancer

Introduction Permanent stoma rates following surgical resection for rectal cancer in England and Wales were reported in the 2012 National Bowel Cancer Audit (NBOCA), for patients diagnosed between 01/08/2008 – 31/07/2010. The report rate for Northumbria Healthcare NHS Trust was 71.7%, resulting in a notification letter from the NHS Information Centre that the rate was higher than expected. This study aimed to establish the permanent stoma rate for patients undergoing formal resection with a date of diagnosis of rectal cancer 01/04/2010–31/03/2013 and assess against the NBOCA reported rate for the prior cohort and the national average of 51% from the 2013 NBOCA report. Method Data were exported from a clinician maintained, prospectively populated database of all patients with colorectal cancer known to the multi-disciplinary team. Permanent stoma rates were calculated by subtracting primary surgery and stoma creation dates from the date of reversal where present. Presence of a stoma >547.5 days (18 months) after primary surgery was regarded permanent, as defined by NBOCA. Results One hundred and eighty-three patients underwent an elective major resection surgery for rectal cancer in this 3 year cohort. The majority (168, 91.8%) had a stoma raised at the time of primary surgery. One patient required a stoma after a return to theatre for anastomotic leak. Of the 102 stomas raised with temporary intent, 80.4% were reversed by 18 months. Reasons for failure to reverse included leaks, disease progression with metastases, debility, death and patient choice. The final permanent stoma rate in patients who underwent major resection was 47.5%. Conclusion This Trust’s stoma rates are in line with the national average and not therefore a cause for concern. This audit did cover a more recent cohort of patients to the 2012 and 2013 NBOCA reports so direct comparisons cannot be made, but stoma rates are unlikely to have changed so significantly. This does raise the question of whether the NBOCA reported rates, derived partly from Open Exeter and partly from Hospital Episode Statistics, are misleading. Accurate granular data requires clinician involvement for capture and submission. The new NBOCA audit platform does facilitate contemporaneous data capture by clinical teams, but is no longer trying to capture this quality metric. It is in the interest of clinical teams and their patients to collect and own their data. Disclosure of interest None Declared.

Bladder augmentation in children and young adults: a review of published literature

ABSTRACTThe objective of this study is to review published literature on bladder augmentation in children and young adults (C&YA) with a neuropathic bladder following a neural tube defect or spinal cord injury to inform nursing practice and patient education. Medline, Embase, CINAHL, PsycINFO and the British Nursing Index were systematically searched to identify studies. The papers reviewed were case studies and medical note review in single centres regarding outcome and post‐operative complications. This limits the generalisability of the findings surrounding outcome and risk of bladder augmentation surgery in C&YA. Evidence suggests irrigation has a role in ongoing bladder management to reduce complications such as bladder calculi. However, data are sparse regarding both appropriate irrigation solutions and the frequency of irrigation necessary to minimise calculi formation. A statistically significant increase is noted in the risk of perforation following bladder augmentation when associated with bladder neck surgery at the time of primary surgery. Limited evidence exists regarding longer term systemic implications of bladder augmentation, such as malignancy or impact on bone mineral density. None of the studies demonstrated an overall improvement in health‐related quality of life (HRQoL) following bladder augmentation. Discrepancies exist between parental and children's HRQoL scores. Bladder augmentation is clinically the standard surgical treatment used to manage refractory neuropathic bladder. However, current evidence demonstrates no improvements to HRQoL following surgery and also describes various complications. Future research in this area is necessary to explore standards of care and most importantly long‐term outcome measures from the patient and professional perspective.

Lipocalin-2 and matrix metalloproteinase-9 expression in high-grade endometrial cancer and their prognostic value.

To demonstrate lipocalin-2 (LCN-2) immunohistochemical expression together with matrix metalloproteinase-9 (MMP-9) protein in high-grade endometrial cancer and determine their correlations with FIGO (International Federation of Gynecology and Obstetrics) stage, histological subtype, presence of vascular invasion, patient age and overall and disease-free survival. Immunohistochemical staining was performed using LCN-2 and MMP-9 antibodies on high-grade endometrial cancer (n=85) diagnosed at Split University Hospital Centre during 1998-2010. Immunohistochemical expression was determined on archived paraffin-embedded samples and scored semiquantitatively. Survival time was analysed using the Kaplan-Meier method, and the log-rank test was used to assess between-group differences. The Cox proportional hazard regression model was used on multivariate survival analysis. Patients were followed from the time of primary surgery until death or last follow-up until December 2012. LCN-2 and MMP-9 were highly expressed in high-grade endometrial cancer. Univariate analysis showed positive immunohistochemical staining for LCN-2 and MMP-9 to be associated with shorter survival in patients with high-grade endometrial cancer. Multivariate analysis showed LCN-2 overexpression to be associated with shorter overall and disease-free survival in high-grade endometrial cancer. Our findings suggest that LCN-2 expression may be an important independent indicator of shorter survival in patients with high-grade endometrial cancer.

Use of fibrin sealant in prevention of hanging palate: A rare complication after cleft palate surgery

Dehiscence of the mucoperiosteal flap from the alveolar margin is one of the rare complications reported after cleft palate surgery. This situation has been termed a hanging palate. [1] In these cases, secondary suturing is bound to fail. Intraoperative use of adhesives can obviate this problem. Although the adhesion system cannot and should not replace surgical suture, it provides valuable assistance in tissue synthesis and in local hemostasis at the time of primary surgery, particularly in cases where conventional suture methods are difficult to apply. In addition to good adhesion and good tissue compatibility, the adhesive is completely absorbed. This paper emphasizes on the effectiveness of the fibrin glue for the prevention of such a complication.

Embryonal Carcinoma in Cryptorchid Abdominal Testis of an Infant.

Cryptorchidism is a known predisposing factor for the development of testicular tumors in adults. Age of patient at the time of treatment of undescended testes has some bearing on the risk of neoplasia. Testicular neoplasia at the time of primary surgery for cryptorchidism has been reported rarely in prepubertal period. We report a case where embryonal carcinoma was detected in a cryptorchid testis of an infant.

"Ovarian Metastases from Colorectal Cancer: Our Experience".

Ovarian metastases from colorectal cancer are uncommon and can present synchronously and metachronoulsy. Role of prophylactic oophorectomy for colorectal cancer is controversial and there is no definitive evidence to support it. A retrospective analysis of all the patients with colorectal cancer who had attended a single unit at our center have been analysed. Clinical presentation, Pathological features and image findings were analyzed. We had 7 patients with ovarian metastases who had presented synchronously or metachronously at our institute. Five patients presented synchronously at the time of primary surgery and 2 patients had presented metachronously after the treatment of primary. Three patients had malignancy in ascending colon and 2 had in sigmoid colon , one in rectosigmoid junction and one case in rectum. The mean overall survival rate was 12.4months (range 6-20months). All the patients received adjuvant chemotherapy. Ovarian metastases is rare in colorectal and occurs in younger patients.

Personalizing the approach to retroperitoneal soft tissue sarcoma: histology-specific patterns of failure and postrelapse outcome after primary extended resection.

To explore patterns of failure and postrelapse outcome of patients with retroperitoneal sarcoma primarily treated by extended resection. All consecutive patients with primary retroperitoneal sarcoma, treated between January 2002 and December 2011 at two European sarcoma centers were included. Five-year overall survival (OS) and crude cumulative incidence (CCI) of local recurrence (LR) and distant metastases (DM) were calculated. Multivariate analyses for OS and CCI of LR and DM were performed. Postrelapse OS was investigated. A total of 377 patients were identified. Median follow-up from the time of primary surgery was 44months [interquartile range (IQR) 27-82]. Five-year OS was 64% [95% confidence interval (CI) 0.588, 0710]. CCI of LR and DM were 23.6% (95% CI 18.9, 29.4) and 21.9% (95% CI 17.6, 27.3), respectively. OS, CCI of LR and DM were 87, 18% and 0 for well-differentiated liposarcoma; 54, 44 and 9% for grade II dedifferentiated liposarcoma; 41,33, and 44% for grade III dedifferentiated liposarcoma; 58, 5, and 55% for leiomyosarcoma; and 85, 4, and 17% for solitary fibrous tumor, respectively. Seventy-six patients developed LR. Median postrelapse follow-up was 27months (IQR 10-58). Twenty-one patients (27%) underwent a second surgical resection (complete in 18), while 55 (73%) did not (22 multifocal, 17 inoperable, 16 other causes). Median postrelapse OS was 17months (IQR 7-31). Well-differentiated liposarcoma histology and disease-free interval predicted postrelapse OS, while surgical resection did not. When primary extended surgery limits LR, histologic subtype and grade determine the outcome. At recurrence, a second surgery is of limited benefit.

Abstract 2850: Biomarkers for detection of exfoliated tumor cells in the peritoneal cavity in rectal cancer

Abstract During tumor growth, and possibly by manipulation during surgery, cells from rectal tumors may be shed into the peritoneal cavity. Such cells may contribute to development of metastatic disease, in the form of peritoneal carcinomatosis. Detection of cancer cells in the peritoneal cavity at the time of primary surgery might therefore be of value for prediction of disease recurrence with subsequent prognostic implications. We previously investigated the incidence of exfoliated cancer cells in peritoneal lavage fluid after resection of locally advanced rectal cancer (LARC). DNA from cells obtained by peritoneal lavage was analyzed with respect to mutations in hotspots of the K-RAS gene. K-RAS mutations were present in 30% of the primary tumors, and were detected in 8% of the lavage fluids examined. The presence of cells with K-RAS mutations in lavage fluid was associated with poor survival, suggesting that a molecular approach for detection of exfoliated tumor cells may be feasible, but K-RAS, although highly specific for detection of tumor cells, is insufficient as the only biomarker. Furthermore, since lavage fluid was collected only at the end of the surgical procedure, the relevance of spontaneous versus iatrogenic tumor cell exfoliation could not be determined. Based on these encouraging results, a prospective study was initiated, in which lavage is performed before and after surgical removal of the primary tumor to provide data regarding the cause of tumor cell exfoliation and their respective contributions to patient outcome. To increase detection sensitivity, a set of highly specific DNA methylation-based biomarkers is explored. In a pilot experiment, a panel of 12 biomarkers has been evaluated in primary tumors from 17 LARC patients using quantitative methylation specific polymerase chain reaction. Methylation of six genes, CNRIP1, MAL, SPG20, FBN1, SNCA and CDO1 was present at high frequencies in this cohort (in 55-88 % of the samples analyzed), and this biomarker panel has been selected for further comparative analysis in lavage samples. The presence of K-RAS, B-RAF and PIK3CA mutations is analyzed using denaturant capillary electrophoresis of PCR-amplified genes. Results from these genetic analyses of the primary tumors and lavage samples of 50 LARC patients will be presented. Citation Format: Annette T. Kristensen, Arne Solbakken, Stein G. Larsen, Karl-Erik Giercksky, Eivind Hovig, Ragnhild Lothe, Guro E. Lind, Marianne G. Guren, Kjersti Flatmark. Biomarkers for detection of exfoliated tumor cells in the peritoneal cavity in rectal cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2850. doi:10.1158/1538-7445.AM2014-2850

Abstract 1088: Differences in metastatic patterns in relation to time between primary surgery and first relapse from breast cancer suggest synchronized growth of dormant micrometastases

Abstract Purpose Compared with most other cancer types, breast cancer has a long natural history. In cases with delayed relapse, the unlinearity of disease progression indicates the presence of periods of tumor dormancy. Clinical and experimental studies indicate that growth might be induced by a physiological event like tissue injury following surgery. In this study we aimed to quantify size and number of metastatic lesions in relation to time between primary surgery and first relapse. Our goal was to find clinical support for the presence of a systemic synchronizing growth signal. Patients and methods All patients (n=209) recorded with metastatic breast cancer at our department during 2004-9 were identified. 180 cases with measurable metastases according to RECIST 1.1 and no metastases at the time of primary surgery (< 2 months), were evaluable. Number of metastatic lesions as well as size of each lesion was recorded at the time of first recurrence. Standard Deviation (SD) of the lesions sizes in each patient was calculated and served as a marker for variability in the metastatic pattern. Patients with a high SD were assumed to have unsynchronized (individual) growth of lesions, whereas patients with low SD were regarded to have synchronized growth. Results Median number of metastatic lesions at first recurrence was 7 (1- >10). Cases with only 1 metastasis (n=38) were excluded from the analyses on SD. Median SD was 5.4 (0.0 - 58). Low SD was significantly associated with low histological grade in primary tumors (Pearson Chi Square p= 0.002), absence of liver metastases (p= 0.001) and presence of lung metastases (p= 0.02). No significant association was found between SD and ER status, Her2 status, nodal status or stage. There was also no significant association between nodal status and time to recurrence (TTR). Patients were grouped according to TTR into two groups; early (< 3years-) or late (> 3 years- after primary diagnosis). In the subgroup of patients that were lymph node negative at primary diagnosis (N0), the median SD was significantly lower in the early group (3.0) when compared with the late group (5.7)(Mann-Whitney U test p= 0.02). This effect was not present in the lymph node positive (N1) patients. Conclusions Our data indicate the presence of a metastatic phenotype characterized by multiple, similar sized metastases. The results support synchronized growth of dormant micrometastases in some cases of breast cancer. The fact that this effect was only present in lymph node negative patients, suggests that micrometastatic tumor dormancy is especially important in this group, with otherwise favorable prognosis. Systemic effects of growth factors released during wound healing following surgery might induce a switch from the dormant state into simultaneous growth of occult micrometastases. Further studies to explore these mechanisms are ongoing. Citation Format: Hanna Dillekås, Monica Transeth, Martin Pilskog, Jörg Assmus, Oddbjorn Straume. Differences in metastatic patterns in relation to time between primary surgery and first relapse from breast cancer suggest synchronized growth of dormant micrometastases. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1088. doi:10.1158/1538-7445.AM2014-1088

320P - Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence

ABSTRACT Aim: The role of sentinel lymph node biopsy (SLNB) in patients with ipsilateral breast tumor recurrence (IBTR) still remains to be elucidated. The aim of this study is to evaluate technical feasibility and validity of performing SLNB in patients with IBTR. Methods: A prospective database of 1176 patients who had breast-conserving surgery (BCS) from January 2005 to December 2013 at Keio University Hospital was analyzed and 35 patients with IBTR underwent SLNB. Sentinel lymph nodes (SLNs) were detected using a combined method of blue dye and radioisotope. Results: The median disease-free interval of 35 patients with IBTR was 66.7 month and the median tumor size of IBTR was 1.2cm. A total of 22 patients had previous SLNB, 8 patients had previous axillary lymph node dissection (ALND), and 5 patients had no previous axillary treatment. The average number of lymph nodes harvested at the time of primary surgery with SLNB and ALND was 2.9 and 20.8, respectively. Among 35 patients with IBTR, repeat BCS (n = 10), nipple sparing mastectomy (n = 10) and total mastectomy (n = 15) were performed as the second surgery. Overall, SLNs were successfully identified in 28 (80.0%) of 35 patients. The identification rate in patients with previous SLNB, ALND and no axillary treatment was 81.8% (18/22), 75% (6/8) and 80% (4/5), respectively. The aberrant lymphatic drainage included the contralateral axillary nodes with 3 patients and the internal mammary nodes with 2 patients. The aberrant drainage was found more frequently in patients with previous ALND comparing with SLNB and no axillary treatment (37.5% vs. 4.5% vs. 0%, p = 0.048). Among 28 patients with successful SLNB, SLN metastases were found in 2 patients. In one patient with previous SLNB, ALND found the positive non-SLN (1/21). The other patients with previous ALND had micrometastasis at the contralateral SLN and did no further axillary treatment. No axillary recurrence was observed after the median follow-up time of 37.3 months from the second surgery for IBTR. Conclusions: SLNB is a technically feasible and valid procedure for staging and treatment of regional lymph nodes in patients with IBTR. Disclosure: All authors have declared no conflicts of interest.

Squamous cell carcinoma of the head and neck outside the oropharynx is rarely human papillomavirus related

The incidence of human papillomavirus (HPV)-driven disease beyond the oropharynx varies greatly in the reported literature. Case series. Two hundred twenty-one samples were strictly classified to the subsites of oral cavity, larynx, or hypopharynx at the time of primary surgery. Formalin-fixed paraffin-embedded samples were subjected to a validated, tiered, diagnostic algorithm of p16 immunohistochemistry, high-risk HPV in situ hybridization, and quantitative polymerase chain reaction for HPV E6 DNA. An additional 60 oropharyngeal cases acted as an internal biological control. An incidence of 4% of HPV-driven cases was observed across the subsites outside the oropharynx compared to 70% of tumors confined within it. This is the first reporting of a broad range of nonoropharyngeal HPV rates using this validated diagnostic algorithm. It remains unclear whether patients with HPV-driven disease originating outside the oropharynx enjoy the same survival advantage apparent in those patients with oropharyngeal squamous cell carcinomas. 4 Laryngoscope, 124:2739-2744, 2014.

“Extended” Sistrunk procedure in the treatment of recurrent thyroglossal duct cysts: A 10-year experience

ObjectiveWe report a 10-year experience of children with recurrent thyroglossal duct cysts (TGDCs) who have been treated using the “extended” Sistrunk procedure. MethodsWe performed a retrospective review of TGDC surgery from 2004 to 2013. Sistrunk operation was the procedure of choice in all patients. Seven children had TGDC recurrence. All of them underwent “extended” Sistrunk procedure. Follow up ranged from 6 months to 8 years. ResultsThere were no gender differences, all recurrences presented within 12 months follow-up in the same location of the primary cyst. Five out of 7 (71%) patients have been treated for preoperative and 2/7 (29%) for postoperative infection at the time of primary surgery. Pathological examination of the surgical specimens showed a single tract in 2 children (29%) and multiple tracts in 5 (71%). We did not observe postoperative complications or further recurrences. ConclusionOur experience suggest that recurrent TGDCs are equally common in both sexes, develop in the same location of the primary cyst and recur more commonly after perioperative infections. The “extended” Sistrunk procedure is highly effective and safe in treating recurrent TGDCs also if multiple duct tracts are detected.

Distraction-Based Treatment Maintains Predicted Thoracic Dimensions in Early-Onset Scoliosis

Study DesignRetrospective cohort study. ObjectiveExamination of distraction-based treatment effect on thoracic dimensions in patients compared to predicted individual normal values, at initial treatment and subsequent follow-up after lengthenings. Summary of Background DataChange in thoracic dimensions and spine length is an important outcome measure in treatment of children with early-onset scoliosis; however, it is difficult to use to make comparisons between patients and the normal population because of the heterogeneous nature of early-onset scoliosis. MethodsEarly-onset scoliosis patients treated with distraction-based therapy who had radiographic parameters (pelvic inlet width, chest width, and thoracic height) preoperatively, immediately postoperatively, and at a minimum 5-year follow-up were included. Individual thoracic measurements were compared with predicted normal measures based on pelvic inlet width, and expressed as a percentile of predicted measure. ResultsComparisons were made in 41 patients; mean age at time of primary surgery was 4.5 years, and median follow-up was 6.5 years. Thoracic height percentile increased from a mean preoperative value of .78 to a postoperative percentile of .88 (p < .001); at long-term follow-up, it was .85. Absolute thoracic height increased at all 3 time points: 141.6, 159.79, and 203.45 mm, respectively Mean chest width was similar preoperatively (170 mm) and immediately postoperatively (166.5 mm) but increased at latest follow-up (206.9 mm). Chest width percentile was similar at all 3 times (.93, .90, and .91). ConclusionsDistraction-based treatment increases absolute thoracic height over time. There is significant improvement in the thoracic height percentile normalized after initial surgery, which was maintained over time. Measuring expected gains as a percentile normalized for pelvic width may be a more relevant outcome measure compared with measuring only absolute values.

Overexpression of platelet-derived growth factor-D as a poor prognosticator in endometrial cancer.

Emerging evidence implicates the platelet-derived growth factor-D (PDGF-D) in many types of human solid tumors. We investigated whether PDGF-D plays an important role in endometrial cancer (EC) in relation to clinicopathologic phenotype, angiogenesis, and patient prognosis. We analyzed PDGF-D protein expression by Western blotting in twenty-seven human endometrial cancer tissues, and matched normal endometrial controls collected at the third Affiliated hospital of Sun Yat-sen University during 2012-2013 (n=27). Immunohistochemical staining was performed using a human PDGF-D antibody on the endometrial cancer patients collected in the same facility during January 2001 and October 2013 (n=152). Patients were followed from the time of primary surgery in 2001-2013 until death or last follow-up. We correlated the PDGF-D expression levels with clinicopathologic parameters and prognosis in human endometrial cancer patients. Compared with matched normal endometrial cases, PDGF-D was up-regulated in endometrial cancer. Expression of PDGF-D protein, found in 78% of the cases, was associated with nonendometrioid histologic type (p=0.028), FIGO stage III/IV (p=0.039), >50% solid tumor growth (p=0.048), pelvic LN metastasis (p=0.035) and ER and PR negativity (p=0.04 and 0.002). PDGF-D expression was also significantly associated with expression of VEGF-A (p=0.021). In multivariate analysis, PDGF-D expression proved to be an independent prognostic factor in addition to histologic grade and FIGO stage. Patients with high expression levels of PDGF-D had a significantly poorer overall survival rate compared with patients with no expression. PDGF-D expression is frequently up-regulated in endometrial cancer, and is associated with aggressive features and poor prognosis.

Early outcome of orchiopexy and analysis of predictive factors: A retrospective study from 2001 to 2010 in a Norwegian regional hospital

Objective. The primary aim of this study was to retrospectively analyse surgical treatment for undescended testes at the Department of Urology, Telemark Hospital, Norway, and to examine whether international standards were met regarding age at surgery and outcome. The secondary aim was to identify factors that predicted an unsuccessful outcome. Material and methods. The department's medical records from 2001 to 2010 were searched, and selected variables were registered and analysed. Results. Of 205 primary orchiopexies, 81% were considered immediately successful and 94% were successful after reoperation. Median age at the time of primary surgery was 3.7 years (range 0.1–17.5 years). Fourteen per cent were operated on before the age of 2 years and 40% before the age of 3 years. There was a tendency towards lower age at surgery in the later part of the study period. Younger patients had an increased risk of a primary unsuccessful result. Procedures performed by a surgeon with a low number of operations were less often successful. Preoperative testicular location and different surgical technique did not affect outcome significantly. Conclusions. The results may seem inferior to those reported by others but comparison is uncertain owing to differences in study design, patient selection criteria and follow-up time. Although age at surgery in this series was higher than recommended, and outcome of the very youngest needs to be improved, the authors argue that the quality of treatment was acceptable. Orchiopexies should be carried out by a limited number of dedicated surgeons in each department.

An analysis of the outcomes for patients with failed primary vitrectomy for rhegmatogenous retinal detachment

Our aim was to identify the timing of retinal redetachments and the prognosis for affected patients. Retrospective review of electronic patient records and casenotes from two centres. Inclusion criteria were failed primary vitrectomy for rhegmatogenous retinal detachment during a 12-year period. Failure was defined as re- or persistent detachment of the retina prior to a further procedure or at final follow-up. The records of 133 cases of failed primary PPV for RRD were analysed. The mean age at time of primary surgery was 62.9 years, and mean follow-up was over 3 years from the date of primary surgery. In 72.9 % of cases, the redetachment was diagnosed within 2 months of the primary surgery. Eighty-five percent were diagnosed within 3 months, 89.5 % within 4 months, and 97.7 % within 6 months. For patients in whom the primary surgery had failed, the rates of attached retina at final follow-up were 80.5 %, or 68.8 % if PVR B/C were present at the time of primary surgery. The final follow-up success rates (attached retina with no tamponade) were 66.2 % for all patients, and 59.4 % for the subset with PVR B/C at the time of primary surgery respectively. Of the total, 33.8 % had one further vitreoretinal procedure, 30.8 % two more, 25.6 % three more, and 5.3 % had four or more. Visual outcome was better with final success (attached retina and no tamponade, p < 0.0001) and worse with PVR B/C evident on diagnosis of failed primary surgery (p < 0.0001). A short duration of follow-up can over-estimate surgeon success rates for retinal detachment repair. For patients in whom primary surgery has failed, the prognosis for ultimate success is markedly lower than for primary surgery, and most patients require two or more further procedures to achieve this.

The economics of using prophylactic antibiotic-loaded bone cement in total knee replacement

The rate of peri-prosthetic infection following total joint replacement continues to rise, and attempts to curb this trend have included the use of antibiotic-loaded bone cement at the time of primary surgery. We have investigated the clinical- and cost-effectiveness of the use of antibiotic-loaded cement for primary total knee replacement (TKR) by comparing the rate of infection in 3048 TKRs performed without loaded cement over a three-year period versus the incidence of infection after 4830 TKRs performed with tobramycin-loaded cement over a later period of time of a similar duration. In order to adjust for confounding factors, the rate of infection in 3347 and 4702 uncemented total hip replacements (THR) performed during the same time periods, respectively, was also examined. There were no significant differences in the characteristics of the patients in the different cohorts. The absolute rate of infection increased when antibiotic-loaded cement was used in TKR. However, this rate of increase was less than the rate of increase in infection following uncemented THR during the same period. If the rise in the rate of infection observed in THR were extrapolated to the TKR cohort, 18 additional cases of infection would have been expected to occur in the cohort receiving antibiotic-loaded cement, compared with the number observed. Depending on the type of antibiotic-loaded cement that is used, its cost in all primary TKRs ranges between USD $2112.72 and USD $112 606.67 per case of infection that is prevented.

Large bowel injuries during gynecological laparoscopy.

Laparoscopy is one of the most frequently preferred surgical options in gynecological surgery and has advantages over laparotomy, including smaller surgical scars, faster recovery, less pain and earlier return of bowel functions. Generally, it is also accepted as safe and effective and patients tolerate it well. However, it is still an intra-abdominal procedure and has the similar potential risks of laparotomy, including injury of a vital structure, bleeding and infection. Besides the well-known risks of open surgery, laparoscopy also has its own unique risks related to abdominal access methods, pneumoperitoneum created to provide adequate operative space and the energy modalities used during the procedures. Bowel, bladder or major blood vessel injuries and passage of gas into the intravascular space may result from laparoscopic surgical technique. In addition, the risks of aspiration, respiratory dysfunction and cardiovascular dysfunction increase during laparoscopy. Large bowel injuries during laparoscopy are serious complications because 50% of bowel injuries and 60% of visceral injuries are undiagnosed at the time of primary surgery. A missed or delayed diagnosis increases the risk of bowel perforation and consequently sepsis and even death. In this paper, we aim to focus on large bowel injuries that happen during gynecological laparoscopy and review their diagnostic and management options.

Molecular profiling and clinical outcome of high-grade serous ovarian cancer presenting with low- versus high-volume ascites.

Epithelial ovarian cancer consists of multiple histotypes differing in etiology and clinical course. The most prevalent histotype is high-grade serous ovarian cancer (HGSOC), which often presents at an advanced stage frequently accompanied with high-volume ascites. While some studies suggest that ascites is associated with poor clinical outcome, most reports have not differentiated between histological subtypes or tumor grade. We compared genome-wide gene expression profiles from a discovery cohort of ten patients diagnosed with stages III-IV HGSOC with high-volume ascites and nine patients with low-volume ascites. An upregulation of immune response genes was detected in tumors from patients presenting with low-volume ascites relative to those with high-volume ascites. Immunohistochemical studies performed on tissue microarrays confirmed higher expression of proteins encoded by immune response genes and increased tumorinfiltrating cells in tumors associated with low-volume ascites. Comparison of 149 advanced-stage HGSOC cases with differential ascites volume at time of primary surgery indicated low-volume ascites correlated with better surgical outcome and longer overall survival. These findings suggest that advanced stage HGSOC presenting with low-volume ascites reflects a unique subgroup of HGSOC, which is associated with upregulation of immune related genes, more abundant tumor infiltrating cells and better clinical outcomes.