Unnecessary Surgery Research Articles

Acute idiopathic scrotal edema (AISE): A case report in Al-Ahsa, Saudi Arabia

Introduction: Acute idiopathic scrotal edema (AISE) is a rare, self-limiting condition of uncertain etiology, predominantly affecting children. It is characterized by sudden scrotal swelling and erythema without involvement of the testes or paratesticular structures. While benign, it can mimic more severe conditions like testicular torsion, requiring careful differentiation to avoid unnecessary surgical interventions. Case Report: We report the case of an 8-year-old boy in Saudi Arabia who presented with acute onset bilateral scrotal swelling, mild erythema, and tenderness, predominantly on the right side. There were no associated fever, trauma, or urinary symptoms. A similar episode two weeks earlier was resolved without medical intervention. Examination revealed generalized scrotal swelling with skin thickening, palpable testicles with normal position and size, and intact cremasteric reflexes. Laboratory results were unremarkable except for mild leukocytosis. Doppler ultrasound showed preserved vascularity of both testicles with characteristic edematous scrotal wall thickening and the “fountain sign,” confirming the diagnosis of AISE. Management and outcome: The patient was managed conservatively with non-steroidal anti-inflammatory drugs (NSAIDs) and intravenous (IV) ceftazidime. The symptoms resolved completely within 48 hours, and he was discharged in good condition with a short course of oral antibiotics. A two-week follow-up showed no recurrence or residual symptoms. Conclusion: This case underscores the importance of recognizing AISE in pediatric acute scrotum presentations to avoid unnecessary surgery. Clinical evaluation and Doppler ultrasound, highlighting the “fountain sign,” are pivotal for diagnosis. Conservative treatment ensures a rapid and favorable outcome, as demonstrated in this case.

The Landmark Series: Testing in Thyroid Nodule Fine Needle Aspiration Cytology.

There has been remarkable growth in our understanding of the biologic behavior and molecular signature of thyroid malignancies, which has led to the introduction, application, and evolution of molecular testing of thyroid nodule FNA cytology. Next-generation sequencing molecular testing is an important, well-validated diagnostic tool for management of cytologically indeterminate thyroid nodules. It reduces unnecessary thyroid surgery for benign disease, avoiding associated surgical risks for the patient and reducing healthcare expenses. This article reviews the development and implementation of thyroid nodule cytologic classification and subsequent testing and how it has improved the diagnostic considerations in thyroid nodule and thyroid cancer management algorithms. The use of molecular testing as a prognostic tool is evolving and although the data are limited, they suggest a promising role in prognostication for oncologic outcomes. However, future studies are needed to further evaluate this.

Incidental Mucinous Neoplasms of the Pancreas: Performance of the AGA, European, and IAP Guidelines in Advising Further Management after Endoscopic ultrasound-guided fine-needle Aspiration Biopsy.

We compared the performance of AGA-2015, ESG-2018, and IAP-2024 guidelines in referring patients for surgery versus surveillance when applied to incidental after diagnosis by EUS-FNA. Single-center, retrospective study with prospective data collection. PLs identified incidentally on CT or MRI/MRCP performed for other diseases with inconclusive imaging results were eligible for analysis. After EUS-FNA and microhistological diagnosis, each of the guidelines was applied; sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were compared. 140 asymptomatic patients (mean age 64.7y, 61% female) had a confirmed diagnosis of MN. Of these, 42 (30%) had "high rik stigmata" and 16 (11.4%) were malignant. AGA-2015, ESG-2018, and IAP-2024, criteria would have advised surgery unnecessarily in 66%, 15%, and 46%, respectively (P<0.001). AGA-2015, ESG-2018, and IAP-2024, and criteria failed to identify 59%, 46.1%, and 33.3% of HGD/IC, respectively (P=1.00). The AGA-2015 criteria were highly specific, while IAP-2024 had superior sensitivity. All had moderate sensitivity to indicate surgery, and all missed similar numbers of malignant lesions. Performing EUS-FNA before application of guidelines seems appropriate to guide further management of asymptomatic PLs, preventing unnecessary surgery and referring patients appropriately for surveillance. The ESG-2018 guideline proved most accurate for this purpose.

Nomogram for pre-procedural prediction of lymph node metastasis in patients with submucosal early gastric cancer.

The treatment of early gastric cancer (EGC) is contingent upon the status of lymph node metastasis (LNM). Accurate preoperative prediction of LNM is critical for reducing unnecessary surgeries. This study seeks to evaluate the risk factors for LNM in submucosal EGC and develop a predictive model to optimize therapeutic decision-making. A retrospective analysis was performed on clinical data from 389 patients with T1b-stage EGC who underwent radical gastrectomy. Univariate and multivariate analyses were conducted to identify independent risk factors, followed by the development of a nomogram to predict LNM. The model's efficacy was validated through receiver operating characteristic curves, calibration curves, and decision curve analysis. Of the 389 patients, 77 had LNM. Logistic regression analysis identified gender, CA199 levels, tumor location, degree of differentiation, presence of ulcers, and lymph node enlargement on CT as independent risk factors for LNM. A nomogram was constructed to assess the risk of LNM, demonstrating strong predictive accuracy with an area under the curve of 0.82 in the training set and 0.74 in the validation set, along with good sensitivity and positive predictive value. This study presents a reliable preoperative nomogram to estimate the likelihood of LNM in submucosal EGC, providing valuable guidance for determining the most effective treatment strategies for patients.

Artificial Intelligence Models May Aid in Predicting Lymph Node Metastasis in Patients with T1 Colorectal Cancer.

Inaccurate prediction of lymph node metastasis (LNM) may lead to unnecessary surgery following endoscopic resection of T1 colorectal cancer (CRC). We aimed to validate the usefulness of artificial intelligence (AI) models for predicting LNM in patients with T1 CRC. We analyzed the clinical data, laboratory results, pathological reports, and endoscopic findings of patients who underwent radical surgery for T1 CRC. We developed AI models to predict LNM using four algorithms: regularized logistic regression classifier (RLRC), random forest classifier (RFC), CatBoost classifier (CBC), and the voting classifier (VC). Four histological factors and four endoscopic findings were included to develop AI models. Areas under the receiver operating characteristics curves (AUROCs) were measured to distinguish AI model performance in accordance with the Japanese Society for Cancer of the Colon and Rectum guidelines. Among 1,386 patients with T1 CRC, 173 patients (12.5%) had LNM. The AUROC values of the RLRC, RFC, CBC, and VC models for LNM prediction were significantly higher (0.673, 0.640, 0.679, and 0.677, respectively) than the 0.525 suggested in accordance with the Japanese Society for Cancer of the Colon and Rectum guidelines (vs RLRC, p<0.001; vs RFC, p=0.001; vs CBC, p<0.001; vs VC, p<0.001). The AUROC value was similar between T1 colon versus T1 rectal cancers (0.718 vs 0.615, p=0.700). The AUROC value was also similar between the initial endoscopic resection and initial surgery groups (0.581 vs 0.746, p=0.845). AI models trained on the basis of endoscopic findings and pathological features performed well in predicting LNM in patients with T1 CRC regardless of tumor location and initial treatment method.

A Multimodal Approach to Symptomatic Endometriosis: A Proposed Algorithm for Clinical Management.

Recent research has proven that peripheral (PS) and central sensitization (CS), mental health, and myofascial dysfunction all play a role, alongside nociception, in the genesis and in the perpetuation of endometriosis' symptoms. However, such components of pain are still largely ignored in clinical practice, although not considering such contributors may entail serious consequences on women's health, including the choice of unnecessary surgery and leaving the real causes of pain untreated. At the present time, we are facing a paradox by which 25-40% of women who undergo laparoscopic surgery for pelvic pain do not have an obvious diagnosis, while the percentage of women with endometriosis who have signs of CS, of depressive or anxiety disorders, or who have an increased pelvic muscle tone ammounts to 41-55%, 15-88% and 28-73%, respectively. Moving from the widely-accepted stepwise approach suggested for endometriosis management, which consists in the initial prescription of low-dose combined oral contraceptives (COCs) or of a progestin monotherapy, followed by GnRH analogues and, ultimately, by surgery, when COCs and progestins have proven ineffective or are not tolerated or contraindicated, we propose an integration of such model which takes into account the identification and the simultaneous treatment of all pain contributors. Our objective is to encourage physicians' awareness of the need of a multidisciplinary, multimodal approach to endometriosis-related pain, and ultimately to promote a reduction in the number of unnecessary surgeries.

Vegetative Pyoderma Gangrenosum Mimicking Squamous Cell Carcinoma: A Poorly Recognized Diagnostic Challenge.

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that is difficult to diagnose due to non-specific clinical, laboratory, and histopathologic features. Distinguishing pseudoepitheliomatous hyperplasia (PEH) from squamous cell carcinoma (SCC) is also histopathologically challenging. The connection between PEH and PG is not well recognized, and instances of PG mimicking SCC are rare. We report a case of vegetative PG accompanied by PEH, originally mistaken for SCC. A 78-year-old woman presented with a 3-month history of an ulcerated, exophytic, and painful mass on her right lower leg. An incisional biopsy revealed PEH and neutrophilic microabscesses, initially raising concerns for SCC keratoacanthoma type with PEH or well-differentiated, infiltrative SCC. However, following additional review of clinical and histopathologic findings at the cutaneous oncology tumor board, the diagnosis of vegetative PG with associated PEH was favored. This case highlights the significance of recognizing PEH as a histopathology feature that can be seen in PG and lead to difficulty distinguishing PG with PEH from SCC. We stress the importance of promptly diagnosing PG through clinical and histopathologic correlation to prevent diagnostic delays and unnecessary surgeries or treatments.

Epiploic appendagitis on the vermiform appendix is often misdiagnosed as acute appendicitis.

Epiploic appendagitis of the vermiform appendix is a rare cause of right lower abdominal pain that can mimic acute appendicitis and result in unnecessary surgery. Despite this, the condition can be managed with non-steroidal anti-inflammatory drugs alone. Due to the lack of characteristic physical or laboratory findings, accurate diagnosis by imaging is crucial. The aim of this case report is to emphasize this uncommon condition to prevent misdiagnosis and avoid unnecessary surgical interventions. A 57-year-old man presented with a 2-day history of abdominal pain and tenderness in the right abdominal region. Laboratory results were within the normal range. The surgeon diagnosed him as distal appendicitis or colonic diverticulitis and treated him with antibiotics, leading to improvement within several days. A subsequent review of the plain computed tomography images by the radiologist detected an oval fat density surrounded by a high-intensity rim and a high-density spot in the center at the tip of normal vermiform appendix. This led to a diagnosis of epiploic appendagitis on the vermiform appendix. Epiploic appendagitis is characterized by inflammation and ischemia resulting from torsion of the epiploic appendage. It can occur not only on the colon but also on the appendix. The imaging findings in this case were typical of epiploic appendagitis on the appendix. It is imperative for clinicians to be familiar with the clinical presentation and imaging findings of epiploic appendagitis on the appendix to ensure an accurate diagnosis, reduce unnecessary surgeries, thereby enhancing patient outcomes.

New Trends of Personalized Medicine in the Management of Abdominal Aortic Aneurysm: A Review.

Abdominal aortic aneurysm (AAA) is a significant vascular condition characterized by the dilation of the abdominal aorta, presenting a substantial risk of rupture and associated high mortality rates. Current management strategies primarily rely on aneurysm diameter and growth rates to predict rupture risk and determine the timing of surgical intervention. However, this approach has limitations, as ruptures can occur in smaller AAAs below surgical thresholds, and many large AAAs remain stable without intervention. This review highlights the need for more precise and individualized assessment tools that integrate biomechanical parameters such as wall stress, wall strength, and hemodynamic factors. Advancements in imaging modalities like ultrasound elastography, computed tomography (CT) angiography, and magnetic resonance imaging (MRI), combined with artificial intelligence, offer enhanced capabilities to assess biomechanical indices and predict rupture risk more accurately. Incorporating these technologies can lead to personalized medicine approaches, improving decision-making regarding the timing of interventions. Additionally, emerging treatments focusing on targeted delivery of therapeutics to weakened areas of the aortic wall, such as nanoparticle-based drug delivery, stem cell therapy, and gene editing techniques like CRISPR-Cas9, show promise in strengthening the aortic wall and halting aneurysm progression. By validating advanced screening modalities and developing targeted treatments, the future management of AAA aims to reduce unnecessary surgeries, prevent ruptures, and significantly improve patient outcomes.

Office-based indocyanine green fluorescent angiography for surgical planning of pedicled flap division

Delayed pedicled flaps are a reliable reconstructive tool for limb salvage. Determining the optimal timing for pedicle division is critical for surgical success and minimizing complications. Assessment of optimal timing has traditionally relied on arbitrary timing or subjective measures. This study explores the use of indocyanine green (ICG) angiography in the office setting as an objective guide for timing the delayed pedicled flap pedicle division, aiming to improve surgical outcomes and resource efficiency. In the outpatient setting, ICG is administered intravenously while the flap pedicle is under tourniquet control. If the distal flap opacifies with the tourniquet still applied, appropriate revascularization has occurred, and the pedicle may be safely divided. We present the example of a 47-year-old male with multiple previous flap reconstructions who eventually required a reverse sural artery flap. Initial intraoperative ICG imaging on postoperative day (POD) 23 revealed insufficient perfusion, prompting the postponement of pedicle division. Subsequent office-based imaging on POD 47 revealed a persistent lack of neovascularization. Adequate vascularization was demonstrated on POD 81, enabling successful pedicle division in the operating room on POD 121 without complications. ICG fluorescent angiography can guide the timing of division for delayed pedicled flaps. We recommend its use in the outpatient setting to decrease unnecessary operating room usage and anesthetic events and reduce the risk of wound healing complications from early pedicle division.

Fine Needle Aspiration Cytology of Palpable Head and Neck Masses: A Descriptive Cross-sectional Study

Introduction: Fine needle aspiration cytology is a quick and safe technique done for the initial diagnosis of head and neck region masses. This study aims to assess the utility of fine needle aspiration cytology in head and neck palpable masses. Materials &amp; Methods: A descriptive cross-sectional study was done in the Pathology Department of Kathmandu Medical College from 1st February 2023 to 31st December 2023. All the patients with palpable head and neck lumps were included in the study. A convenience sampling method was used. The data was entered and analyzed using the Statistical Package for Social Science (SPSS) version 22.0 Results: Among 650 fine needle aspiration cytology done during the study period, 184 were from head and neck lesions (28.30%). The mean age of the patient was 35.4 years with female predominance. The most common site was lymph node 85 (46.19%) followed by thyroid 39 (21.19%). Reactive lymphadenitis was the most common cause of lymphadenopathy seen in 41(22.2%) patients and colloid goitre was the most common cause of thyroid swelling seen in 26(14.13%) patients. Conclusions: Fine needle aspiration cytology is a useful and reliable technique for the diagnosis of head and neck mass. It helps to avoid unnecessary surgeries and is recommended and guides the clinician in general clinical management.

DAIR for periprosthetic joint infections—One week to save the joint?

BackgroundPredicting the success of a Debridement, Antibiotics, and Implant Retention (DAIR) procedure for periprosthetic joint infection (PJI) for hip and knee joint arthroplasty remains a challenge. A failed DAIR might adversely affect the outcome of any future revision surgery for PJI. Hence, the ability to identify and optimize factors predictive of DAIR success would help target the procedure to the appropriate patient cohort and avoid unnecessary surgery for patients where a DAIR is unlikely to eradicate infection.MethodsA retrospective review of our prospective Bone Infection Group database was performed to identify all patients who underwent a DAIR of their primary or revision hip or knee arthroplasty. All patients had a confirmed PJI as per MSIS 2013 criteria and an outcome according to the MSIS working group outcome-reporting tool. DAIR surgery was then grouped into groups of “successful” or “unsuccessful” outcomes.ResultsSixty-four consecutive patients with an acute PJI underwent a DAIR procedure between 2009 and 2020, with 46 procedures performed for knees and 18 for hips. Treatment was successful in 69% (37 knees and 7 hips). The chance of a successful DAIR was significantly greater if performed at or within one week of symptom onset compared to greater than one-week duration (adjusted odds ratio (OR) 0.11; P = 0.027; 95% CI [0.02–0.78])). For DAIR performed at or within one week of symptom onset, the success rate was 93% for knees and 80% for hips. The chance of a successful DAIR however was not influenced by whether the surgeon was an arthroplasty or non-arthroplasty surgeon (OR 0.28; P = 0.13; 95% CI [0.05–1.48])). Isolated Streptococcus infection had a success rate of 100%. Next came Coagulase-negative Staphylococci (71%) and Methicillin-susceptible Staphylococcus Aureus (65%). Polymicrobial infection had the worst outcome, with a success rate of 40%.ConclusionIn our experience, DAIR surgery performed within one week of symptom onset significantly increased the chance of successful infection eradication. Collaborative work is required to ensure arthroplasty patients can access prompt appropriate surgical decision-making as soon as concerns arise, remove barriers to early assessment and minimise delays to surgery.

The Effect of Genital Aesthetic Surgery on Body Image Cathexis and Sexual Function in Women.

The emotions that women generally feel about the appearance of their bodies cause them to turn to aesthetics surgery. This study was conducted to determine the effect of genital aesthetic surgery on body image cathexis and sexual function in women. This descriptive-prospective study was conducted between November 1, 2022, and July 30, 2023, with 50 women who applied to the gynecology service in a training and research hospital. Sociodemographic and descriptive characteristics questionnaire, body image cathexis scale, and female sexual function index were filled out before surgery. The patients whose contact information was obtained were called by phone 2 months after surgery and the body image cathexis scale and the female sexual function index were administered again. Frequency analysis, t-test, and one-way analysis of variance were used to evaluate the data. Significance was accepted as p<0.05. The average age of the women was 39.26±10.28 (22-68) and the mean body mass was 25.39±4.55 (17.6-39.8). The majority of women (44%) underwent perineoplasty. It was observed that the level of body cathexis after genital aesthetics surgery was significantly higher than the preoperative body cathexis, and the general level of sexual function, desire, arousal, orgasm, and satisfaction level increased significantly after surgery. Female genital aesthetics surgery was found to improve body cathexis and increase sexual function in women. In order to reduce unnecessary female genital aesthetic surgery, education should be planned on this subject and public awareness about genital appearance should be increased. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Primary Lymphoma of the Female Genital Tract: A Needle in a Haystack

Primary lymphoma of the female genital tract (PLFGT) is a rare entity with nonspecific symptoms. Its prognosis relies on accurate and quick diagnosis and therapy despite the lack of standardized management guidelines. This study aimed to explore the clinicopathologic and radiologic characteristics; and differential diagnoses of women with lymphoma of the female genital tract (FGT) treated at the same institution. A retrospective study was conducted on 22 cases diagnosed with lymphoma of their FGT during the study period from June 2016 and December 2023. Medical records and radiologic, pathologic, management, and survival data were collected. The mean age was 49.45 yr, and the mean follow-up duration was 48 mo. Only 15 cases were diagnosed with PLFGT, while the remaining 7 cases were secondary to the disease. The ovary was the predominant site (9 cases), and diffuse large B-cell lymphoma was the main histologic subtype (90.9%). Eleven (50%) patients underwent surgery. PLFGT demonstrated a more favorable outcome (60% achieved complete remission). Treatment strategies and Ann Arbor staging were significantly correlated with overall survival. To avoid misdiagnosis, it is essential to include lymphoma in the differential diagnosis of histologically difficult gynecologic neoplasms. Increasing awareness about this rare entity and providing a preoperative diagnosis is paramount to avoid unnecessary gynecologic surgery.

Somewhere over the Rainbow

Abstract This research pertains to the rights of intersex children in the Global South. Kenya presents an interesting comparison as there has been litigation concerning intersex children. The 2014 case of Baby ‘A’ presents a wealth of knowledge. The jurisprudence developed in this regard touches on some of the provisions in the United Nations Convention on the Rights of the Child i.e. the four important general principles identified therein. These general principles are crucial in protecting the rights of vulnerable children and issues of gender, gender identity and sex – in particular, intersex children. In Uganda, the situation is quite dire. There are interesting questions regarding the right to health care, bodily autonomy, possible over-reach of medical professionals and legislative over-reach amongst many other issues. A comparison is made with India. In 2019 the state of Tamil Nadu, a court banned such unnecessary gender-normalising surgeries. While not an African country, it provides a comparative nuance in understanding sogiesc issues in the Global South.

The Evil Twins of Chronic Pelvic Pain Syndrome: A Systematic Review and Meta-Analysis on Interstitial Cystitis/Painful Bladder Syndrome and Endometriosis.

Chronic pelvic pain is a debilitating condition affecting quality of life. Endometriosis is one of the leading causes of CPP, but recent studies highlighted the role of interstitial cystitis/bladder pain syndrome (IC/PBS) in causing CPP. Only some studies addressed the coexistence of these two conditions, which seems more frequent than what is supposed, leading to diagnostic delays and unnecessary surgeries. This systematic review aimed to evaluate the estimate of the prevalence of the comorbidity of endometriosis and IC/PBS. We performed a systematic review of the literature indexed on PubMed, Scopus, ISI Web of Science, and Cochrane using a combination of keywords and text words represented by "painful bladder syndrome", "endometriosis", "interstitial cystitis", and "bladder pain syndrome". We performed a meta-analysis of the results. The meta-analysis shows that the coexistence of endometriosis and IC/PBS in women with CPP ranged from 15.5% to 78.3%, which is higher than the prevalence of IC/PBS in the general population. Prevalence data about the coexistence of endometriosis and IC/PBS are highly heterogeneous, probably due to the paucity of available data. However, in cases of endometriosis unresponsive to treatment, other reasons for CPP (such as IC/PBS) need to be ruled out.

Radiomics-based nomogram for predicting total knee replacement in knee osteoarthritis patients

BackgroundThe incidence of total knee replacement (TKR) surgeries has increased, partly attributed to healthcare policies that cause premature and potentially unwarranted interventions. This has raised concerns regarding a potential trend of excessive surgeries. PurposeThis study aimed to propose a predictive model based on digital radiography (DR) radiomics to objectively assess the need for TKR surgery in patients with knee osteoarthritis (KOA) and to improve risk stratification, thereby avoiding unnecessary surgeries. MethodsA retrospective study was conducted on 1,785 KOA patients from January 2017 to December 2022. Radiomics features were extracted from DR images to quantify lesion phenotypes, followed by a two-step feature selection to derive robust signatures. Multiple models were constructed using independent risk factors and radiomics features, and these models were validated using logistic regression. The performance of the models was evaluated via receiver operating characteristic (ROC) curves, area under the curve (AUC), calibration curves, and decision curve analysis. A multivariable Cox regression-derived nomogram was used to predict operation-free survival (OFS), and the patients were categorized into high- or low-risk groups based on risk stratification. Kaplan-Meier curves were used to compare OFS between the two groups. ResultsDuring a follow-up period of at least one year, 962 of 1785 (53.89 %) patients underwent TKR. Age, presence of radiographic KOA (RKOA), and Kellgren–Lawrence (KL) grading were identified as independent risk factors for OFS. The combined RKOA model (including age, presence of RKOA, and Radscore; AUC = 0.969) and combined KL model (including age, KL grading, and Radscore; AUC = 0.968) showed similar performance, with both significantly outperforming other models (p < 0.001). The 1-, 2-, and 3-year AUCs for the RKOA nomogram were 0.891, 0.916, and 0.920, respectively, whereas those for the KL nomogram were 0.890, 0.914, and 0.931. The thresholds of 68.92 (RKOA nomogram) and 64.41 (KL nomogram) were derived from the median nomogram scores and used to stratify patients into high- and low-risk groups. K–M curves demonstrated that the risk stratification system effectively distinguished between high- and low-risk groups, with the high-risk group being more likely to require TKR. ConclusionsTwo nomograms incorporating age, RKOA (or KL grading), and Radscore were developed to predict 3-years OFS for KOA patients and establish risk thresholds, potentially guiding personalized non-surgical treatments during the OFS period.

An improved non-dominated sorting genetic algorithm II for distributed heterogeneous hybrid flow-shop scheduling with blocking constraints

Distributed manufacturing is a new trend to accommodate the economic globalization, which means multiple geographically-distributed factories can collaborate to meet urgent delivery requirements. However, such factories may vary due to layout adjustments and equipment aging, thus the production efficiency greatly depends on the allocation of orders. This scenario is frequently found in energy-intensive process industries, e.g., chemical and pharmaceutical and industries, where the lack of buffers usually results in extra non-blocking constraints and makes the production scheduling even harder. Therefore, this paper investigates a distributed heterogeneous hybrid blocking flow-shop scheduling problem (DHHBFSP) for minimizing the makespan and total energy consumption simultaneously, and proposes an improved non-dominated sorting genetic algorithm II (INSGA-II) to address the problem. First, two heuristic algorithms, i.e., bi-objective considered heuristic (BCH) and similarity heuristic (SH), are developed for the population initialization. Then, to speed-up the local search, a comparison method for non-dominated solutions is proposed to reserve more solutions that are likely to be further improved. Afterwards, a probabilistic model is developed to eliminate unnecessary operations during local search processes. Finally, the proposed INSGA-II is tested on benchmark instances and a real-world case for the validation. Numerical experiments suggest that the SH can generates high-quality solutions within a very short period of time, and the BCH has significantly improved average IGD and HV values for the initial population. Besides, the probabilistic model saves considerable computational time for the local search without compromising the solution quality. With the help of these strategies, the proposed INSGA-II improves average IGD and HV values by 68 % and 57 % for the basic NSGA-II respectively, and obtains better Pareto fronts compared to existing multi-objective algorithms on the majority of test instances. Moreover, the industrial case study shows that the proposed INSGA-II is capable of providing solid scheduling plans for a pharmaceutical enterprise with large-scale orders.

BN SO29 - Overinvestigation and unnecessary surgery for Gallbladder Polyps: An audit of compliance with ESGAR guidelines

Abstract Background Incidental gallbladder polyps are increasingly reported on abdominal ultrasound and have a theoretical association with increased risk of gallbladder cancer. Most gallbladder polyps are actually gallstones and there is little evidence for any survival benefit or reduced rates of gallbladder cancer in patients under ultrasound surveillance. ESGAR guidelines attempt to standardize and rationalize surveillance protocols, balancing the risks of missed early cancers versus the costs of surveillance investigations. This audit aims to assess the investigation and management of gallbladder polyps as per ESGAR guidelines at a single NHS trust. Method An audit was conducted at a single NHS Trust in England. Searches were conducted on the electronic patient record for patients coded for K82.8 (Gallbladder pathology: other) from 01/01/2022 to 31/12/2023. Patient records were examined for radiological imaging confirming diagnosis of gallbladder polyp. Data was analysed using Microsoft excel and compared with the 2021 ESGAR guidance on management of gallbladder polyps. Results 97 patients were included. All polyps were diagnosed with abdominal ultrasound. Patients had, on average, two ultrasounds. 51% were seen in outpatients clinic. 35 patients (36%) underwent laparoscopic cholecystectomy (including all patients with a polyp &amp;gt;10mm). Histology confirmed diagnosis of cholecystitis (69%), pseudopolyp (9%), gallbladder polyp (6%) and IPMN (3%). 74% (26/35) of patients that underwent cholecystectomy had biliary symptoms and 77% (20/26) had cholecystitis confirmed by histology. Despite having biliary symptoms at first assessment, 47% of polyp patients went on to have two ultrasounds and two clinic appointments. Conclusion The study confirms that the majority of ultrasound detected polyps are not neoplastic, and patients undergo multiple hospital visits, incurring significant non-therapeutic costs. Adherence to ESGAR guidelines is inconsistent. In the symptomatic cohort, however, a low threshold for laparoscopic cholecystectomy should be considered given the high likelihood of underlying stones.

OGC SO22 - Accuracy of CT and FDG/PET clinical staging within a dedicated multidisciplinary service for patients with oesophago-gastric cancer

Abstract Background Accurate staging for oesophago-gastric cancer is important in ensuring correct treatment pathways, avoiding unnecessary surgery and providing prognostication for patients. Previously, cross sectional imaging in accurately providing tumour (T) and nodal (N) staging has been variable for upper GI malignancies, with usage of invasive investigations such as EUS to provide more specific local staging. With the increased utilisation of specialist multidisciplinary involvement and improved technology, we aimed to assess whether CT and PET imaging may be able to provide sufficiently accurate staging required for treatment decision making. Method All patients who underwent oesoophagogastric resections between January 2022 and March 2024 were identified from our surgical database. Patients were included if they had oesophago-gastric cancer, and underwent curative resection without neo-adjuvant treatment. Data collected included age, gender, location of primary tumour, CT/PET staging, and final histology. Outcomes assessed included rate of understaging in clinical and pathological T and N staging, and sensitivity and specificity of imaging in identifying presence of nodal disease. Results 38 patients were included in this analysis. For oesophageal and GOJ cancers, T stage under-reporting occurred in 6/27 (22%) patients, and N under-reporting in 7/27 (27%) patients. Radiological staging correlated with final pathological staging in 55% of T staging and 59% of N staging. Sensitivity (55.56%, 95% CI 21-86%) and specificity (72.2%, 95% CI 46.5-90.3%) for nodal disease on CT/PET was low, however no tumour or nodal under-staging would have impacted management. Gastric cancer staging accuracy assessment was limited by small numbers (n=12), however T under-staging occurred in 5/12 (42%) patients and N under-staging occurred in 5/11 patients (45%). Conclusion Involvement of dedicated radiology services in multidisciplinary care for oesophago-gastric cancer provides adequate radiological staging to guide treatment. Gastric cancer clinical staging requires laparoscopic and endoscopic assessment for accurate tumour assessment and management guidance. Radiological under-staging is less common in oesophageal and GOJ tumours than gastric cancer and has minimal impact on patient management.