Timing Of Surgical Management Research Articles

The Impact of Preoperative Breast MRI on Timing of Surgical Management in Newly Diagnosed Breast Cancer.

Purpose: Preoperative breast MRI has been recommended at our center since 2016 for invasive lobular carcinoma and cancers in dense breasts. This study examined how preoperative breast MRI impacted surgical timing and outcomes for patients with newly diagnosed breast cancer. Methods: Retrospective single-center study of consecutive women diagnosed with new breast cancer between June 1, 2019, and March 1, 2021, in whom preoperative breast MRI was recommended. MRI, tumour histology, breast density, post-MRI biopsy, positive predictive value of biopsy (PPV3), surgery, and margin status were recorded. Time from diagnosis to surgery was compared using t-tests. Results: There were 1054 patients reviewed, and 356 were included (mean age 60.9). Of these, 44.4% (158/356) underwent preoperative breast MRI, and 55.6% (198/356) did not. MRI referral was more likely for invasive lobular carcinoma, multifocal disease, and younger patients. Following preoperative MRI, 29.1% (46/158) patients required additional breast biopsies before surgery, for a PPV3 of 37% (17/46). The time between biopsy and surgery was 55.8 ± 21.4 days for patients with the MRI, compared to 42.8 ± 20.3 days for those without (P < .00001). MRI was not associated with the type of surgery (mastectomy vs breastconserving surgery) (P = .44) or rate of positive surgical margins (P = .52). Conclusion: Among patients who underwent preoperative breast MRI, we observed significant delays to surgery by almost 2 weeks. When preoperative MRI is requested, efforts should be made to mitigate associated delays.

8744 Factors Associated with Oophorectomy Among Pediatric Ovarian Torsion Patients

<h3>Study Objective</h3> Ovarian torsion (OT) is the fifth most common gynecologic emergency, with one-third of cases occurring in females younger than 20 years-old. We aimed to evaluate factors associated with oophorectomy at the time of surgery for suspected OT in our pediatric population. <h3>Design</h3> Retrospective cohort analysis. <h3>Setting</h3> Tertiary, academic medical center. <h3>Patients or Participants</h3> Patients less than 18 years of age undergoing surgery for suspected ovarian torsion between 2016-2021. <h3>Interventions</h3> Evaluation of patient demographics, presentation timeline, imaging characteristics, and surgical variables associated with oophorectomy as well as perioperative outcomes. <h3>Measurements and Main Results</h3> Forty-five pediatric patients underwent surgical management for suspected ovarian torsion. Five patients were excluded for planned management of antenatally diagnosed ovarian masses, of which 3 underwent oophorectomy. Of the 40 included patients, 26 (65%) were confirmed to be torsed intra-operatively. Seventeen of these patients (66%) underwent ovarian preserving surgery (OPS) while 9 (34%) underwent unilateral oophorectomy (UO). Between the UO and OPS group, there were no differences in age or race. There were no differences in ultrasound findings including absent flow, enlarged ovary, and peripheral follicles; however, the UO group had significantly larger associated ovarian masses (12.48cm vs 8.06cm, p = .015). The median time from presentation to surgical start was 480 minutes (IQR 336-800.75) in the OPS group versus 868 minutes (IQR 257.5-1353.5) in the UO group. There was no association with primary surgical service (Pediatric Surgery versus Gynecology) however time from presentation to OR was significantly faster amongst patients treated by gynecologists (p=0.018). 50% of oophorectomy patients had a minimally invasive approach compared to 78.6% in the OPS group; however, this varied significantly by surgical specialty. <h3>Conclusion</h3> Given the significant sequelae associated with oophorectomy, current standards in surgical management of OT recommend conservative, ovarian-preserving techniques. Our data supports that delayed time to surgery and larger adnexal masses are associated with oophorectomy at the time of surgical management.

Assessment of Midterm Functional Outcomes Following Talar Extrusion Injuries

Category:Ankle; Hindfoot; TraumaIntroduction/Purpose:Open talar dislocations with complete or partial extrusion of the talus are rare, high energy injuries associated with major complications including infection, avascular necrosis and post-traumatic arthritis. These are debilitating injuries with significant long-term effects including avascular necrosis and post traumatic arthritis. Functional outcome data in the literature is limited and predominantly consists of case reports and few single centre case series. Historically these injuries have been treated with talectomy and tibiocalcaneal arthrodesis, however there has been a subsequent trend towards debridement and reimplantation with preservation of the extruded talus. Our aim was to evaluate mid-term functional outcomes, assess complication profile and need for secondary surgery in a single-centre series of cases treated with reimplantation.Methods:All talar extrusion injuries presenting between January 2015 and January 2018 were identified from the trauma database search at our major trauma centre. Inclusion criteria was defined as open talar dislocations associated with either complete or partial extrusion of the talus. Case-note review was performed collecting baseline demographic data including age, gender, injury mechanism, associated injuries, Gustilo-Anderson grade, smoking and diabetes status, and method and timing of surgical management. Twelve patients were identified with a mean follow-up of 3 years (minimum 26 months). Primary outcome measure was functional outcome assessed using the Manchester-Oxford Foot Questionnaire (MOxFQ). Results for each of the three domains were converted to a 0-100 scale for comparison. Secondary outcomes included complication rate and all cause re- operation ratesResults:Mean age was 37.8 years (17-74 years). Five patients (42%) had total talar extrusion without fracture and 7/12 (58%) sustained fracture-dislocation with partial talar extrusion. All were Gustilo-Anderson grade III. All underwent successful reimplantation with 8/12 (67%) treated with single stage surgery, and 4/12 (33%) in two stages. The mean MOxFQ scores for total talar extrusions versus partial talar extrusions with fracture were 79 (range 9-18) vs 41 (range 0-86) for walking domain, 65 (range 45-80) vs 42 (range 0-90) for pain domain, and 63 (range 38-75) vs 48 (range 19-51) for social domain. One patient (8%) developed avascular necrosis, 3/12 (25%) developed infection and 1/12 (8%) patient eventually required below knee amputation. One (8%) patient underwent secondary surgery fusion for post-traumatic arthritis.Conclusion:Our series demonstrates the serious ramifications of sustaining talar extrusions. Patients who sustain these injuries should expect persistent functional deficit and pain at mid-term follow-up. Functional outcomes are relatively poor. The data demonstrates a trend towards better functional outcomes in patients who have partial extrusion of the talar dome with associated fractures, compared to ligamentous total talar extrusion injuries. The incidence of avascular necrosis, deep infection and secondary surgery in our cohort supports reimplantation as an effective treatment strategy.

Does Size Matter?

Infective endocarditis continues to be a challenging problem for the clinician given the varied clinical presentations, the options for medical management, and the complexities regarding the need for and timing of surgical management. The in-hospital mortality rate for infective endocarditis remains high at 15% to 20% with a 1-year mortality rate approaching 40%. There has been a trend toward earlier surgical management in appropriate candidates. The major reasons for early surgery are heart failure, uncontrolled infection, and prevention of embolization.

A67 DELAYED PRESENTATION AND SURGICAL MANAGEMENT OF PRIMARY PNEUMOCOCCAL PERITONITIS

Abstract Background S. pneumoniae intraabdominal infections are rare in healthy individuals, but the literature reveals a female dominance for primary peritonitis in the early post-partum period. Limited studies exist evaluating the timing of surgical management. Aims We present a case of primary pneumococcal peritonitis in which the presentation and surgical intervention was delayed. Methods A case chart review and literature review was conducted. Results A 41-year-old female with a spontaneous vaginal delivery 4 months prior presented with progressive abdominal pain, distention, and emesis over 10 days. She was septic with a firm, distended abdomen and rebound tenderness. A CT revealed significant panenteritis and ascites. She received intravenous fluids and was empirically started on ceftriaxone, vancomycin and metronidazole. The gastrointestinal virus panel, stool cultures and C. difficile toxin were negative. However, her blood cultures revealed Strep. pneumoniae and the purulent peritoneal fluid contained gram-positive cocci. Despite sensitivity to ceftriaxone, and several paracenteses, her ascites, pain and new fever continued. Twenty-eight days after admission, she underwent a laparoscopic abdominal lysis of adhesions and drainage of three intraabdominal abscess collections. Cultures of the purulent peritoneal fluid were negative. She was stepped down to amoxicillin-clavulanate and discharged six weeks after symptom onset. Despite the development of pneumococcal vaccines, worldwide S. pneumoniae is a common pathogen with high morbidity and mortality. It is a rare cause of intraabdominal infections; however, primary peritonitis has been widely recognized in children. Prior to antibiotics, the mortality of pneumococcal peritonitis was 31.5–100%. Secondary pneumococcal peritonitis is established in adult patients with cirrhosis, nephrotic syndrome and immunocompromised conditions. In healthy individuals, pneumococcal peritonitis often mimics appendicitis and is diagnosed with positive blood cultures. The majority of primary pneumococcal peritonitis cases occur in females, are associated with the early post-partum period (less than two months), IUD placement, and pelvic inflammatory disease. Theories of pathogenesis include direct hematogenous spread or translocation. Transient colonization of the genital tract after IUD placement or during the post-partum period may allow for ascension from the fallopian tubes into the peritoneum. The majority of cases undergo surgery within one week of symptom onset. While it has not been studied in randomized trials, early surgical intervention for source control may decrease morbidity and hospital stay. Conclusions Primary pneumococcal peritonitis has a female predominance and can occur later in the post-partum period than previously reported. Surgery should be considered early to achieve source control and improve patient outcomes. Funding Agencies None

Endometrioma surgery and possibilities of early disease control

Aim: The purpose of this study is to investigate the efficacy of surgical management in ovarian endometrioma for early disease control and long-term fertility preservation in adolescents and women of very young age. A history of cyclic pains in adolescents is highly associated with endometriosis. Sonography enables the diagnosis of small endometriomas 1-2 cm in diameter. Although it is obvious that the risk of damage to normal ovarian tissue is diminished when operating and removing a 2 cm endometrioma, it is not approved since there are currently no tools available to identify at-risk patients. Additionally, performing laparoscopic surgery with 5 mm instruments in patients with small endometriomas will likely cause more harm than benefit. Methods: A literature review was performed using key words for endometrioma surgery, in vitro fertilization (IVF), implantation rate, pregnancy rate and adolescents. The pros and cons of surgical removal prior to assisted reproductive therapy (ART), outcomes of endometrioma surgical treatment before IVF, and current recommendations for endometrioma removal were investigated. Results: The total patient population from articles supporting removal of endometrioma before assisted reproductive therapy and evidence against were 30,741 and 9983 respectively. However, the only study reporting a statistically significant result found an 8.2% implantation rate for the surgical removal group vs . 12% in the direct-to-IVF group, and 14.9% pregnancy rate in the surgical removal group vs . 24.9% in the direct-to-IVF group. Damage to ovarian reserve and function due to surgery is exacerbated by large cyst size, stripping of the pseudocapsule and older age. Larger endometrioma, ablation of the endometrioma base and younger age are associated with higher recurrence rate. Conclusion: The patient’s age, in addition to the size and type of endometrioma, can direct and indicate the timing of surgical management. Bilateral endometriomas and those larger than 7 cm are associated with more damage to ovarian reserve due to disease and surgery, as compared with unilateral lesions and those smaller than 7 cm. High-risk adolescents and very young women seeking fertility treatment can thus benefit from an early diagnosis of endometrioma. Treatment by trans vaginal hydro-laparoscopy of selected cases can probably be suggested for the treatment of small endometriomas, since 5fr instruments are used following microsurgery principles. Therefore, an early diagnosis of endometrioma, especially in young patients, must be encouraged, improved and standardized, through stepwise clinical reasoning and diagnostic testing.

P149. Timing of surgical decompression for cauda equina syndrome

BACKGROUND CONTEXT Cauda equina syndrome (CES) is a devastating spinal condition without a clear consensus on evidence-based treatment guidelines and reported patient outcomes. Due to the relative infrequency of this condition at individual institutions, the majority of the studies that investigate CES are underpowered with results that are difficult to apply to the general population. PURPOSE The purpose of this investigation was to use a large, nationwide patient sample of CES patients to identify demographic and procedural trends and recognize factors that influence outcomes. STUDY DESIGN/SETTING This investigation was a retrospective cohort study that identified patients with CES registered in the Nationwide Inpatient Sample (NIS) database from 2000 to 2014. PATIENT SAMPLE Patients were identified using the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) code for cauda equina syndrome (344.61) and the ICD-9-CM procedure code for either disc excision (8051) or spinal canal exploration and decompression (0309). Demographic analysis included patient age, sex, median income per patient's zip code, and presenting institution (urban teaching vs urban non-teaching vs rural). ICD-9-CM codes for lumbar disc herniation (722.10, 722.73), spinal stenosis (724.02), tumor (198.5), postoperative hematoma (998.12), and trauma (806.4) were utilized to identify the most frequent etiologies of CES. OUTCOME MEASURES Outcome measures were retained for each observation, including inpatient mortality, total complications, postoperative length of stay, total charges, discharge disposition, average total charges and urinary catheterization rates. METHODS The impact of surgical timing on outcomes was investigated by separating patients into an early surgical intervention cohort (surgery on hospital day 0 or 1) versus a delayed intervention cohort (surgery on hospital day 2 or later). Patient outcomes and trends in the timing of surgical decompression were analyzed using linear regression. RESULTS A total of 20,924 cauda equina syndrome patients met inclusion criteria. Following adjustment for age, sex, race and median area code income, the delayed surgical intervention group was associated with significant differences including increased inpatient mortality (OR 9.60, p=.002), total complications (OR 1.41, p=.018) and non-routine discharge (OR 2.37, p CONCLUSIONS This study represents the largest investigation to date examining trends and outcomes in patients with CES. The results reveal that the timing of surgical management in CES patients has not changed appreciably from 2000-2014 despite mounting evidence of the benefit of early decompression. CES patients that undergo surgical decompression on hospital day 0 or 1 are observed to have improved inpatient outcomes, including lower complication and mortality rates. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Long-term radiographic and clinical-functional outcomes of isolated, displaced, closed talar neck and body fractures treated by ORIF: the timing of surgical management

BackgroundThe main purpose of this retrospective case series study was to evaluate long-term radiographic and clinical outcomes of a consecutive series of patients diagnosed with isolated, displaced, closed talar neck or body fractures treated by open reduction and internal fixation (ORIF). Secondly, the aim was to verify the influence of the location of talar fractures on the outcomes, the prognostic value of the Hawkins sign, whether operative delays promote avascular necrosis (AVN) and if the fractures require emergent surgical management.MethodsFrom January 2007 to December 2012, at our institution, 31 patients underwent ORIF through the use of screws. On the basis of Inokuchi criteria, the injuries were divided between neck and body fractures, which were classified according to Hawkins and Sneppen, respectively. The patients included were divided into two groups in relation to fracture location and complexity. Radiographic assessment focused on reduction quality, bone healing, the Hawkins sign and post-traumatic arthritis (PTA) development. For the clinical evaluation, clinical-functional scores (AOFAS Ankle-Hindfoot Score; MFS; FFI-17; SF-36) and VAS were determined, and statistical analysis was performed.Results27 patients, 19 males and 8 females, mean age 38.3 years, were included with an average follow-up period of 83.2 months (range 49–119). There were 9 neck and 19 body fractures; their reduction was anatomical or nearly anatomical in 22 cases, and all reached radiographic consolidation after a mean period of 3.4 months (range 1.7–7). The Hawkins sign was observed in 9 cases, in which necrosis did not develop. With a 0–11 day surgical timing interval, more than 60% of the patients obtained good or fair results with different scores, while 18 (66.7%) were completely satisfied (VAS: 9–10). The early complications included malunions (21.4%) and wound problems (25%); the late complications involved AVN (25%) and PTA (78.6%).ConclusionsDespite a high rate of long-term complications, satisfactory clinical results were achieved. Talar fracture location did not influence the outcomes, the Hawkins sign was confirmed as a positive prognostic factor, and operation timing did not influence AVN development. Hence, these injuries do not require emergent surgical management by ORIF.

Relationship of locus of control and depression to treatment adherence in gynecologic oncology patients

CAH and EIN who underwent any type of hysterectomy. Of these patients, 2315 had concurrent bilateral or unilateral oophorectomy (83.2%). Occult ovarian cancer was found in 27 of these cases, representing an overall risk of 1.2%. Stratified by age, 15 of 1838 women b65 years of age and 12 of 477 who were ≥65 years old had ovarian cancer on final pathology, representing an 0.8% and 2.5% risk of ovarian cancer in these age groups, respectively. We determined the relative risk of occult ovarian malignancy at the time of surgical management of CAH to be 3.1 at age ≥65 vs. age b65 years (relative risk 3.08, 95% CI 1.5–6.5, Fisher's exact test P b 0.006). Conclusions: Conventional management of CAH/EIN in women who have completed childbearing does not differ from that of endometrial cancer, including total abdominal hysterectomy/bilateral salpingooophorectomy. This practice is compelled by the theoretical risk of continued hormonal stimulation of residual endometrial disease, the risk of a synchronous ovarian malignancy, and the risk of metastasis to the ovary. Studies endorsing the safety of hormone replacement therapy in endometrial cancer patients argue against the detrimental effect of estrogen in endometrial cancer patients and, therefore, in CAH/ EIN as well. Our study demonstrates a low incidence of ovarian malignancy in women with CAH/EIN, especially in women b65 years of age, providing compelling evidence to support ovarian preservation. As data increase regarding the health benefits of ovarian preservation in postmenopausal women, a paradigm shift in the surgical management of CAH in these same women should follow.

Limited training exposure in intraoperative radiation therapy (IORT) may result in omission of its use in treating locally advanced gynecologic malignancies

CAH and EIN who underwent any type of hysterectomy. Of these patients, 2315 had concurrent bilateral or unilateral oophorectomy (83.2%). Occult ovarian cancer was found in 27 of these cases, representing an overall risk of 1.2%. Stratified by age, 15 of 1838 women b65 years of age and 12 of 477 who were ≥65 years old had ovarian cancer on final pathology, representing an 0.8% and 2.5% risk of ovarian cancer in these age groups, respectively. We determined the relative risk of occult ovarian malignancy at the time of surgical management of CAH to be 3.1 at age ≥65 vs. age b65 years (relative risk 3.08, 95% CI 1.5–6.5, Fisher's exact test P b 0.006). Conclusions: Conventional management of CAH/EIN in women who have completed childbearing does not differ from that of endometrial cancer, including total abdominal hysterectomy/bilateral salpingooophorectomy. This practice is compelled by the theoretical risk of continued hormonal stimulation of residual endometrial disease, the risk of a synchronous ovarian malignancy, and the risk of metastasis to the ovary. Studies endorsing the safety of hormone replacement therapy in endometrial cancer patients argue against the detrimental effect of estrogen in endometrial cancer patients and, therefore, in CAH/ EIN as well. Our study demonstrates a low incidence of ovarian malignancy in women with CAH/EIN, especially in women b65 years of age, providing compelling evidence to support ovarian preservation. As data increase regarding the health benefits of ovarian preservation in postmenopausal women, a paradigm shift in the surgical management of CAH in these same women should follow.

Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer.

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient's demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Timing in the surgical evacuation of spinal epidural abscesses.

One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes. A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts. Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18-87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87). Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.

Ovarian Presevation at Time of Surgical Management for Benign Adnexal Pathology

Ovarian Presevation at Time of Surgical Management for Benign Adnexal Pathology

Surgical Thresholds for Bicuspid Aortic Valve Associated Aortopathy

This systematic review seeks to present the outcomes of the natural history of aortopathy associated with bicuspid aortic valve (ABAV) and after interventions. Aortopathy is common in patients with ABAV, and early intervention has been proposed to reduce the risk of dissection. In asymptomatic patients, the timing of surgical management is based upon imaging of aortic size, but the actual threshold is based upon observational data and expert opinion. As evidence of high risk would justify early intervention, we sought to define the natural history of this condition and after interventions. We undertook a systemic review of the evidence from observational studies of ABAV published up to June 2013. The primary outcome was annualized all-cause mortality. Secondary outcomes included acute aortic events, rates of aneurysm enlargement, and peri-operative complications. A random-effects model was used to combine outcomes. A meta-regression was undertaken to assess the impact of potential covariates. The 32 eligible papers involved 11,045 patients (9,441 BAV and 1,604 control subjects, age 46 ± 14 years). There were 3 major groups, nonoperated bicuspid aortic valve (BAV) patients (ages from 30 to 40 years), patients after aortic surgery (generally 40 to 60 years of age) and after isolated valve replacement (>60 years of age). The respective annualized mortality of nonoperated BAV patients was 0.56% (95% confidence interval [CI]: 0.13 to 0.99), compared with 0.78% (95% CI: 0.20 to 1.36) in patients after aortic surgery and 2.39% (95% CI: 1.61 to 3.16) after isolated valve replacement. The annualized acute event rate in nonoperated BAV patients was 0.29% (95% CI: 0.23 to 0.35), this risk being no different from that of a tricuspid aortic valve (risk ratio: 0.68, 95% CI: 0.34 to 1.36). In the post-surgical series, 30-day mortality varied from 0% to 2.5%, and the risk of acute events was 0.16% (95% CI: 0.0 to 0.32) in patients after aortic surgery and 0.68% (95% CI: 0.42 to 0.94) after isolated valve replacement. Aortic dilation was at a rate of 0.16mm/year over 6 decades in healthy BAV subjects and 1.1 ± 0.15 mm/year in older aortic valve replacement patients. The risk associated with ABAV varies according to age and clinical setting. Nonetheless, despite aortic dilatation, the acute aortic event risk of ABAV appears low in current practice. Decision-making regarding the timing of intervention needs to be made on the basis of the balance between this low risk and both the morbidity and mortality of surgery.

Delayed Repair of Lateral Orbital Wall and Orbital Floor Fracture

Timing of surgical management of facial fractures may differ from the current standard when an associated severe ophthalmologic injury exists; this may necessitate a delay in repair to protect the patient's vision. We set out to demonstrate that good functional and aesthetic outcomes can be achieved in cases where zygoma bone fracture repair had to be delayed for more than 21 days after injury with a specific surgical plan.Using the electronic database from Montreal General Hospital, a level I trauma center, a retrospective review of all facial fractures occurring from 1994 to 2009 was performed. Our review returned a total of 22,727 trauma patients admitted to Montreal General Hospital. Of these, 2672 sustained 1 or more facial fractures. Among the facial trauma patients, 945 patients' injuries included a zygoma fracture, 324 (35.3%) of which were managed operatively. Seven cases had their surgery delayed for more than 21 days after injury, 2 of which were managed using simple osteotomies and plate fixations, without the need for bone grafts. Both patients demonstrated a satisfactory outcome with improvement relative to their preoperative status. We provide a detailed description of our most recent case of a 73-year-old woman in whom the surgical repair of the lateral orbital rim and orbital floor was delayed for 10 weeks to allow healing of her associated traumatic retinal detachment.For patients with associated ocular injuries who cannot undergo orbital fracture repair within 21 days of the trauma, delayed surgery may still result in an acceptable aesthetic result.

Pathogenesis, Diagnosis, and Management of Severe Pelvic Inflammatory Disease and Tuboovarian Abscess

Severe pelvic inflammatory disease and tuboovarian abscesses (TOAs) are common pelvic infections requiring inpatient admission. There are few large randomized trials guiding appropriate clinical management of TOA, including antibiotic selection and timing of surgical management and drainage. The pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and TOA are summarized and reviewed from the most current literature.

Diagnosis and managementof pheochromocytoma in pregnancy

：Objective To discuss thediagnosis and management of pheochromocytoma in pregnancy. Methods Three cases ofpheochromocytoma in pregnancy were managed from 2007- 2009.Case 1, a 41-year-old womanpresented with paroxysmal hypertension during 27+1 weeks' gestation.The accompaniedsymptoms included dizziness, palpitation and sweating. Both B ultrasound and MRI revealeda right adrenal tumor about 7 cm in diameter. The 24-hour catecholamine was higher thannormal. A diagnosis of right adrenal pheochromocytoma was made. Case 2, a 28-year-oldwoman presented with hypertension during 12+4 weeks' gestation. B ultrasound showed aright adrenal tumor about 5 cm in diameter. The 24-hour catecholamine was higher thannormal. Case 3, a 32-year-old woman presented with hypertension during 14+3 weeks'gestation. B ultrasound revealed bilateral adrenal tumors. The 24-hour catecholamine washigher than normal. The diagnosis of bilateral adrenal pheochromocytomas was made. ResultsThe first patient delivered a healthy female infant through cesarean section at 32 weeks'gestation. Laparoscopic resection of right adrenal pheochromocytoma was successfullyperformed at the same time. Both the second and third patients had elective abortion forfear of fetotoxicity. Case 2 accepted laparoscopic resection of right adrenalpheochromocytoma after 4 weeks' medical preparation. Case 3 rejected surgery. Thehistopathological findings proved pheochromocytoma in case 1 and case 2. ConclusionsPheochromocytoma should be included in the defferential diagnosis in hypertensionoccurring during pregnancy especially in the following situations:hypertension duringearly pregnancy; paroxymal hypertension accompanied by headache, palpitation and sweating;hypertension does not relieve after delivery. Early diagnosis and management with medicaltreatment followed by surgical removal usually results in good maternal and fetaloutcomes. The second trimester is good timing of surgical management. Laparoscopic removalof pheochromocytoma is safe in pregnancy.

Effect of external valvuloplasty of the deep vein in the treatment of chronic venous insufficiency of the lower extremity

This study was conducted to verify the efficacy of external valvuloplasty of the femoral vein in the treatment of primary chronic venous insufficiency (PCVI). Forty patients with PCVI of the bilateral lower extremities were enrolled at the time of surgical management. All 80 limbs were classified as CEAP C2 to C4, with moderate incompetence of the deep vein. The limbs of each patient were randomized into one of two groups according to the operative method, so that when one limb was randomized to group A, regardless of whether it was the right or left limb, the other limb was assigned to group B. In group A, external valvuloplasty of the femoral vein was combined with surgery of the superficial venous system; in group B, surgery of the superficial venous system alone was performed. The therapeutic effects between the limbs in groups A and B were compared by color duplex scanning, a color Doppler velocity profile, air plethysmography (APG), and a CEAP severity score at 1 month, 1 year, and 3 years postoperatively. Within each group of limbs, no significant differences were found in the average operative time within each group of limbs. The varicose veins resolved, there were no deep vein thromboses, and the wounds healed well postoperatively in all cases. Leg heaviness was relieved completely in 90% of group A limbs (36/40) and 55% of group B limbs (22/40). Venous valve competence was achieved in 100%, 98.1%, and 90.9% of group A limbs at 1 month, 1 year, and 3 years postoperatively, respectively. The amount of venous reflux, APG indices, and CEAP severity scores were not significantly different between the two groups preoperatively (P > .05). The amount of venous reflux, reflux indices, CEAP severity scores, and muscle pumping indices improved markedly in group A limbs postoperatively compared with group B limbs (P < .01); muscle pumping indices did not improve significantly in group B limbs postoperatively (P > .05). There were significant differences in the amount of venous reflux, reflux indices, and CEAP severity scores between group A and B limbs at 1 month and 1 year postoperatively (P < .01). There were significant differences in all parameters assessed between group A and B limbs 3 years postoperatively (P < .05). External valvuloplasty of the femoral vein combined with surgical repair of the superficial venous system improved the hemodynamic status of the lower limbs, restored valvular function more effectively, and achieved better outcomes than surgical repair of the superficial venous system alone.

Uterine Didelphys with Duplicated Upper Vagina and Bilateral Lower Vaginal Agenesis: A Series of a Novel Complex Congenital Anomaly of the Female Reproductive Tract and Surgical Management

Background: Complex congenital anomalies of the female reproductive tract are due to absence or dysregulation of the interactions of the Müllerian system and urogenital sinus. In this case series, two uncommon anomalies, agenesis of the lower vagina and uterus didelphys, were found to co-exist in three adolescent patients presenting challenging clinical dilemmas. Timing of surgical management and post operative care are reviewed.

Indication and Timing of Thyroid Surgery for Patients with Hereditary Medullary Thyroid Cancer Syndromes

Hereditary medullary thyroid cancer syndromes comprise familial medullary thyroid cancer (FMTC) and multiple endocrine neoplasia types 2A and 2B. Hereditary medullary thyroid cancers have an autosomal dominant pattern of inheritance and are caused by activating germline point mutations in the RET proto-oncogene. Evaluation of the onset, extent, and progression of hereditary medullary thyroid cancer associated with specific RET mutations has enabled clinicians to treat patients based on the level of risk associated with their specific mutation. Children identified by RET screening to be at risk for the development of medullary thyroid cancer can be treated with prophylactic thyroidectomy before developing the disease. This review covers the diagnosis, evaluation, timing of surgical management, and optimal follow-up of patients with hereditary medullary thyroid cancer syndromes.