Downstaging after preoperative chemoradiation for locally advanced rectal cancer is associated with better survival than pathologic stage 0-1 disease treated with upfront surgery.

BACKGROUND AND OBJECTIVES: It is unknown how patients with locally advanced rectal cancer with significant response to preoperative radiotherapy/chemoradiotherapy fare relative to patients with true pathologic 0-1 disease undergoing upfront surgery. We aimed to determine whether survival is improved in locally advanced rectal cancer downstaged to pathologic stage 0-1 disease compared to true pathologic stage 0-1 tumors. METHODS: A retrospective review of the National Cancer Database between 2004 and 2016 was conducted. Three groups were identified: (1) clinical stage 2-3 disease downstaged to pathologic stage 0-1 disease after radiotherapy, (2) clinical stage 2-3 disease not downstaged after radiotherapy, and (3) true pathologic 0-1 tumors undergoing upfront surgery. The primary endpoint was overall survival and was compared using Kaplan-Meier and multivariate Cox regression analyses. RESULTS: The study population consisted of 59,884 patients. Of the 40,130 patients with locally advanced rectal cancer treated with preoperative radiation, 12,670 (31.5%) had significant downstaging (group 1), while 27,460 (68.4%) had no significant downstaging (group 2). A total of 19,754 had pathologic 0-1 disease treated with upfront resection (group 3). On Kaplan-Meier analysis, downstaged patients had significantly better overall survival compared to both non-downstaged and true pathologic stage 0-1 patients (median 156 vs. 99 and 136 months, respectively, p < 0.001). On multivariate analysis, downstaged patients had significantly better survival (HR 0.88, p < 0.001) compared to true pathologic 0-1 patients. CONCLUSIONS: Locally advanced rectal cancer downstaged after preoperative radiotherapy has significantly better survival compared to true pathologic stage 0-1 disease treated with upfront surgery. Response to chemoradiotherapy likely identifies a subset of patients with a particularly good prognosis.

Novel antibiotic irrigation device versus standard O-ring wound retractor in the prevention of surgical site infection following colorectal resection.

PURPOSE: We sought to compare the effectiveness of a novel antibiotic irrigation device to the standard O-ring wound retractor in preventing surgical site infections (SSIs) following colorectal resections. METHODS: This single-arm clinical trial included patients undergoing colorectal resections utilizing the novel device. A retrospective cohort of patients undergoing the same procedures with the O-ring retractor was selected as the control group. The primary outcome assessed was SSI. Secondary outcomes assessed were overall complications, hospital length of stay (LOS), and 30-day readmission. A univariable and multivariable logistic regression model was built to evaluate the association between SSI as the outcome variable and the use of the novel device as the main independent variable. The model was adjusted for any confounding variables. RESULTS: Eighty-six novel device cases and 170 O-ring retractor cases were enrolled. There were no significant differences between the two groups in terms of demographics and preoperative comorbidities. Cases with the novel device had fewer Pfannenstiel incisions (1.2% vs. 14.6%, p < 0.001). There were no other significant differences in intraoperative variables. SSI rates were significantly lower in the novel device group (1.2% vs. 9.1%, p = 0.014). There were no other significant differences in postoperative complications. Multivariable logistic regression with backward elimination showed that the use of the novel device was significantly more effective against SSI by 92.5% compared to the use of the O-ring retractor. CONCLUSION: The novel device may contribute to lower SSI rates compared to the O-ring retractor following colorectal resection.

Does coffee affect bowel recovery following minimally invasive colorectal operations? A three-armed randomized controlled trial.

PURPOSE: Previous studies have suggested that coffee may shorten the postoperative ileus period. We sought to evaluate the impact of both coffee and caffeine on shortening the return of postoperative bowel function following minimally invasive colectomy. METHODS: This was a single-center, randomized controlled clinical trial conducted in a tertiary hospital. Patients undergoing an elective robotic or laparoscopic small or large bowel operation were included in this study. Patients were randomized into one of three groups: warm water, decaffeinated coffee, and caffeinated coffee. Subjects were assigned to drink a 4-oz cup three times daily starting on postoperative day one. The primary endpoint was time to first bowel movement. Secondary endpoints included time to first flatus, length of hospital stay, and postoperative morbidity. RESULTS: A total of 99 patients were included in this study: 31 warm water, 31 decaffeinated coffee, and 37 caffeinated coffee. The groups were similar in age and sex (p = 0.51 and 0.91, respectively). Mean (SD) time to the first bowel movement in days was 2.94 (1.4), 2.58 (1.2), and 2.86 (1.3), respectively (p = 0.53). There were no significant differences observed in postoperative morbidity (p = 0.52) between groups. Multivariate linear regression analysis did not reveal a statistically significant association between any interventions and time to first bowel movement or length of hospital stay. CONCLUSIONS: Coffee (caffeinated or decaffeinated) does not expedite the return of bowel function following minimally invasive operation. TRIAL REGISTRATION: https://classic. CLINICALTRIALS: gov/ct2/show/NCT02639728 NCT02639728.

Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans.

PURPOSE: Sleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk. METHODS: Within one VA healthcare system, women identified through electronic health record data as having one or more factors (e.g., age >50 years, hypertension) associated with SDB, completed telephone screening in preparation for an SDB treatment study and answered questions about prior care related to SDB diagnosis and treatment. RESULTS: Of 319 women, 111 (35%) reported having completed a diagnostic sleep study in the past, of whom 48 (43%) were diagnosed with SDB. Women who completed a diagnostic study were more likely to have hypertension or obesity. Those who were diagnosed with SDB based on the sleep study were more likely to have hypertension, diabetes, or be ≥50 years old. Of the 40 women who received treatment, 37 (93%) received positive airway pressure therapy. Only 9 (24%) had used positive airway pressure therapy in the prior week. Few women received other treatments such as oral appliances or surgery. CONCLUSIONS: Findings support the need for increased attention to identification and management of SDB in women veterans, especially those with conditions associated with elevated SDB risk.

Bilateral Gluteal Fasciocutaneous Advancement Flaps With and Without Tie-Over Sutures in Treatment of Chronic Pilonidal Disease: A Prospective Case Series.

PURPOSE: Flap procedures following pilonidal excision have high recurrence and dehiscence rates. We present a cosmetic, outpatient technique to reconstruction via bilateral gluteal fasciocutaneous advancement flaps with and without tie-over sutures. METHODS: This is a prospective case series of 51 patients (40 males and 11 females). Following elliptical excision of pilonidal disease, gluteal fasciocutaneous advancement flaps were elevated circumferentially using blunt, discontinuous dissection, and a multilayered closure was performed. The resulting scar was midline. Thirty-five patients (68.6%) also had two full-thickness, compressing sutures tied over rolled up gauze. RESULTS: Patients had a mean age of 28.2 and body mass index of 26.8. Eight (15.9%) were smokers and 11 (21.6%) were obese. At a mean follow-up of 38.7 months, there were no recurrences and 19 (37.3%) patients had wound dehiscence. There was no significant difference in dehiscence between patients with and without tie-over sutures (31.4% vs 50%, P = 0.20). There was no significant difference in dehiscence between smokers and non-smokers, (62.5% vs 41.9%, P = 0.47), or between obese and non-obese patients (36.4% vs 46.3%, P = 0.51). Obese patients with tie-over sutures had significantly less dehiscence compared to obese patients without tie-over sutures (14% vs 75%, P = 0.03). CONCLUSION: Bilateral gluteal fasciocutaneous advancement flap with consideration of tie-over sutures is an outpatient treatment for chronic pilonidal disease with resultant midline scar and with no recurrence in our series.

Predictors of lymph node metastases in patients with malignant adenomatous polyps of the colon.

BACKGROUND: We sought to describe predictors of lymph node positivity in patients with malignant colon polyps to identify low risk patients who may potentially avoid radical surgery. DESIGN: The National Cancer Database (2010-2015) was queried for all patients with malignant colonic polyps who underwent formal colonic resection. Univariate and multivariate methods were used to determine independent predictors of lymph node metastasis. RESULTS: 14,663 patients were identified. Lymph node disease was present in 9% of patients. High-grade disease, LVI, PNI, younger age, and left sided location were univariate predictors of lymph node disease. High-grade disease (OR 1.84), left sided location (OR 1.31), LVI (OR 5.79), and PNI (OR 1.70) were independent predictors, while elderly age (OR 0.64) was protective (all p-values <0.001). Elderly patients with low grade disease of the right/transverse colon without LVI/PNI had a 4.4% risk of lymph node disease. High grade, left-sided tumors with LVI, non-elderly age, had a 30% risk. CONCLUSION: Non-elderly age, left-sided location, LVI, PNI and high-grade histology are independent predictors of lymph node metastasis in malignant colonic polyps.

Targeted deletion of PAC1 receptors in retinal neurons enhances neuron loss and axonopathy in a model of multiple sclerosis and optic neuritis.

Chronic inflammation drives synaptic loss in multiple sclerosis (MS) and is also commonly observed in other neurodegenerative diseases. Clinically approved treatments for MS provide symptomatic relief but fail to halt neurodegeneration and neurological decline. Studies in animal disease models have demonstrated that the neuropeptide pituitary adenylate cyclase-activating polypeptide (PACAP, ADCYAP1) exhibits anti-inflammatory, neuroprotective and regenerative properties. Anti-inflammatory actions appear to be mediated primarily by two receptors, VPAC1 and VPAC2, which also bind vasoactive intestinal peptide (VIP). Pharmacological experiments indicate that another receptor, PAC1 (ADCYAP1R1), which is highly selective for PACAP, provides protection to neurons, although genetic evidence and other mechanistic information is lacking. To determine if PAC1 receptors protect neurons in a cell-autonomous manner, we used adeno-associated virus (AAV2) to deliver Cre recombinase to the retina of mice harboring floxed PAC1 alleles. Mice were then subjected to chronic experimental autoimmune encephalomyelitis (EAE), a disease model that recapitulates major clinical and pathological features of MS and associated optic neuritis. Unexpectedly, deletion of PAC1 in naïve mice resulted in a deficit of retinal ganglionic neurons (RGNs) and their dendrites, suggesting a homeostatic role of PAC1. Moreover, deletion of PAC1 resulted in increased EAE-induced loss of a subpopulation of RGNs purported to be vulnerable in animal models of glaucoma. Increased axonal pathology and increased secondary presence of microglia/macrophages was also prominently seen in the optic nerve. These findings demonstrate that neuronal PAC1 receptors play a homeostatic role in protecting RGNs and directly protects neurons and their axons against neuroinflammatory challenge. SIGNIFICANCE STATEMENT: Chronic inflammation is a major component of neurodegenerative diseases and plays a central role in multiple sclerosis (MS). Current treatments for MS do not prevent neurodegeneration and/or neurological decline. The neuropeptide pituitary adenylate cyclase-activating polypeptide (PACAP) has been shown to have anti-inflammatory, neuroprotective and regenerative properties but the cell type- and receptor-specific mechanisms are not clear. To test whether the protective effects of PACAP are direct on the PAC1 receptor subtype on neurons, we delete PAC1 receptors from neurons and investigate neuropathologigical changes in an animal model of MS. The findings demonstrate that PAC1 receptors on neurons play a homeostatic role in maintaining neuron health and can directly protect neurons and their axons during neuroinflammatory disease.

Learning curve in robotic colorectal surgery.

With the rapid adoption of robotics in colorectal surgery, there has been growing interest in the pace at which surgeons gain competency, as it may aid in self-assessment or credentialing. Therefore, we sought to evaluate the learning curve of an expert laparoscopic colorectal surgeon who performed a variety of colorectal procedures robotically. This is a retrospective review of a prospective database of 111 subsequent colorectal procedures performed by a single colorectal surgeon. The cumulative summation technique (CUSUM) was used to construct a learning curve for robotic proficiency by analyzing total operative and console times. Postoperative outcomes including length of stay, 30-day complications, and 30-day readmission rates were evaluated. Chi-square and one-way ANOVA (including Kruskal-Wallis) tests were used to evaluate categorical and continuous variables. Our patient cohort had a mean age of 62.4, mean BMI of 26.9, and mean ASA score of 2.41. There were two conversions to open surgery. The CUSUM graph for console time indicated an initial decrease at case 13 and another decrease at case 83, generating 3 distinct performance phases: learning (n = 13), competence (n = 70), and mastery (n = 28). An interphase comparison revealed no significant differences in age, gender, BMI, ASA score, types of procedures, or indications for surgery between the three phases. Over the course of the study, both mean surgeon console time and median length of stay decreased significantly (p = 0.00017 and p = 0.016, respectively). Although statistically insignificant, there was a downward trend in total operative time and postoperative complication rates. Learning curves for robotic colorectal surgery are commonly divided into three performance phases. Our findings contribute to the construction of a reliable learning curve for the transition of colorectal surgeons to robotics. Furthermore, they may help guide the stepwise training and credentialing of new robotic surgeons.

Adenosquamous carcinoma: An aggressive histologic sub-type of colon cancer with poor prognosis.

BACKGROUND: Studies have reported worse overall survival (OS) for adenosquamous carcinoma (ASC) compared to adenocarcinoma (AC) of the colon, but none have analyzed a national dataset for over 30 years. METHODS: The National Cancer Database was queried from 2004 to 2016 for patients with ASC and AC of the colon. Kaplan-Meier survival analysis was performed to assess OS. Descriptive variables were evaluated using independent T-test and Chi-square analyses. RESULTS: 332 ASC patients were compared to 496,950 AC patients. AC patients were older than ASC patients (68.6 vs. 64.4 years); p < 0.001. Most ASC cancers presented with stage IV (41.3%) and poorly-differentiated disease (57.5%) compared to AC (22.4% and 17.7%). OS of the ASC cohort was 13.9 months. Median OS for stage IV AC versus stage IV ASC was significantly better (14.1 vs. 8.0 months); p < 0.0001. CONCLUSION: This is the largest national database study to compare ASC with AC. Our findings confirm that unlike AC, ASC most frequently presents late stage, as poorly-differentiated lesions, and have worse OS.

Sleep apnea in women veterans: results of a national survey of VA health care users.

STUDY OBJECTIVES: The goals of this study were to estimate rates of undiagnosed, diagnosed, and treated sleep apnea in women veterans and to identify factors associated with diagnosis and treatment of sleep apnea in this population. METHODS: A large nationwide postal survey was sent to a random sample of 4,000 women veterans who had received health care at a Veterans Health Administration (VA) facility in the previous 6 months. A total of 1,498 surveys were completed. Survey items used for the current analyses included: demographics; sleep apnea risk, diagnostic status, and treatment; symptoms of other sleep disorders (eg, insomnia); mental health symptoms; and comorbidities. RESULTS: Among responders, 13% of women reported a prior sleep apnea diagnosis. Among women who reported a diagnosis of sleep apnea, 65% reported using positive airway pressure therapy. A sleep apnea diagnosis was associated with older age, higher BMI, non-Hispanic African American/Black racial/ethnic identity, being unemployed, other sleep disorder symptoms (eg, insomnia), depression and post-traumatic stress disorder symptoms, and multimorbidity. Among women without a sleep apnea diagnosis, 43% scored as "high risk" on the STOP (snoring, tiredness, observed apneas, blood pressure) questionnaire. High risk scores were associated with older age, higher BMI, African American/Black identity, other sleep disorder symptoms (eg, insomnia), mental health symptoms, and multimorbidity. Only BMI differed between women using vs not using positive airway pressure therapy. CONCLUSIONS: Women veterans with diagnosed sleep apnea were commonly treated with positive airway pressure therapy, which is standard first-line treatment; however, many undiagnosed women were at high risk. Efforts to increase screening, diagnosis, and treatment of sleep apnea in women with comorbid mental and physical health conditions are needed.

Role of right hemicolectomy in patients with low-grade appendiceal mucinous adenocarcinoma.

BACKGROUND: There is little consensus with regards to the most appropriate surgical management for low-grade appendiceal mucinous adenocarcinomas (LAMA), though right hemicolectomy is usually recommended. METHODS: The SEER database was queried for all patients with non-metastatic LAMA. Disease specific and overall survival was compared by surgery type: 1) appendectomy, 2) formal right hemicolectomy 3) non-formal colectomy (including ileocecectomy). RESULTS: A total of 579 patients with non-metastatic LAMA were identified. 133 (23%), 404 (70%), and 42 (7%) of patients had stage I, II, and III disease, respectively. 99 (17.1%) had appendectomy, 87 (15%) had non-formal colectomy, and 302 (52.2%) had formal right hemicolectomy. We observed no significant differences in disease specific or overall survival by surgery type. Controlling for age and stage, surgery type was not a significant predictor of disease specific or overall survival. CONCLUSION: In patients with localized LAMA, right hemicolectomy did not increase disease specific or overall survival. Right hemicolectomy should be reserved for LAMA patients with positive margins post appendectomy.

PACAP/PAC1 Regulation of Inflammation via Catecholaminergic Neurons in a Model of Multiple Sclerosis.

The sympathetic nervous system (SNS) serves to maintain homeostasis of vital organ systems throughout the body, and its dysfunction plays a major role in human disease. The SNS also links the central nervous system to the immune system during different types of stress via innervation of the lymph nodes, spleen, thymus, and bone marrow. Previous studies have shown that pituitary adenylate cyclase-activating polypeptide (PACAP, gene name adcyap1) exhibits anti-inflammatory properties in the experimental autoimmune encephalomyelitis (EAE) model of multiple sclerosis. Because PACAP is known to regulate SNS function, we hypothesized that part of the immunoprotective action of PACAP is due to its neuromodulatory effects on sympathetic neurons. To examine this, we used an inducible, targeted approach to conditionally disrupt not only the PACAP-preferring PAC1 receptor gene (adcyap1r1) in dopamine ß-hydroxylase-expressing cells, which includes postganglionic sympathetic neurons, but also catecholaminergic neurons in the brain and adrenomedullary chromaffin cells. In contrast to our previous EAE studies using PACAP global knockout mice which developed severe and prolonged EAE, we found that mice with conditional loss of PAC1 receptors in catecholaminergic cells developed a delayed time course of EAE with reduced helper T cell type 1 (Th1) and Th17 and enhanced Th2 cell polarization. At later time points, similar to mice with global PACAP loss, mice with conditional loss of PAC1 exhibited more severe clinical disease than controls. The latter was associated with a reduction in the abundance of thymic regulatory T cells (Tregs). These studies indicate that PAC1 receptor signaling acts in catecholaminergic cells in a time-dependent manner. At early stages of disease development, it enhances the ability of the SNS to polarize the Th response towards a more inflammatory state. Then, after disease is established, it enhances the ability of the SNS to dampen the inflammatory response via Tregs. The lack of concordance in results between global PACAP KO mice and mice with the PAC1 deletion targeted to catecholaminergic cells during early EAE may be explained by the fact that PACAP acts to regulate inflammation via multiple receptor subtypes and multiple targets, including inflammatory cells.

Correction to: PACAP/PAC1 Regulation of Inflammation via Catecholaminergic Neurons in a Model of Multiple Sclerosis.

The original version of this article unfortunately contained mistakes. The captured article title and corresponding author were incorrect.

Graded fear generalization enhances the level of cfos-positive neurons specifically in the basolateral amygdala.

Fear is an important emotional reaction in response to threatening stimuli and is important for survival. However, when fear occurs in inappropriate circumstances, it can lead to pathological conditions including an increased vulnerability for developing anxiety disorders such as posttraumatic stress disorder (PTSD). Patients with PTSD generalize fear to contexts or to environments that are not associated with the trauma. We sought to explore if increasing the level of dissimilarity relative to the context in which mice learn fear results in changes in the level of fear responding to the new context. We also determined with this procedure if the number of cells expressing the immediate early gene cfos changes with the corresponding level of expressed fear within brain regions known to be important in modulating fear, including the basolateral amygdala (BLA) and hippocampus. Our results indicate that mice that were tested in increasingly different contexts showed significantly different levels of fear responses. Freezing level was higher in the context most similar to the acquisition context than the one that was highly different. The level of cfos within the BLA, but not hippocampus, was also significantly different between the test contexts, with higher levels in the somewhat similar compared with the most different context. Overall, these results highlight the BLA as a critical region in the node of fear circuitry for modulating fear generalization. © 2016 Wiley Periodicals, Inc.

Sonographic evaluation of polycystic ovaries.

The morphological features of the ovaries in women with polycystic ovary syndrome (PCOS) have been well described by ultrasound imaging technology. These include enlarged ovary size, multiple small follicles of similar size, increased ovarian stromal volume and echogenicity, peripheral distribution of the follicles, and higher stromal blood flow. Ultrasound identification of the presence of polycystic ovarian morphology (PCOM) has been recognized as a component of PCOS diagnosis. With the advance of ultrasound technology, new definition has been proposed recently. There is, however, a paucity of data for the ovarian morphology in normal and PCOS adolescents. Magnetic resonance imaging has the potential to be an alternative imaging modality for diagnosing PCOM in adolescence.

Antimüllerian hormone, antral follicle count and ovarian volume predict menstrual cycle length in healthy women.

OBJECTIVE: Although menstrual cycle length is one of the main concerns of women and may have important health consequences, little is known about its predictors. The aim of this study was to identify predictors of menstrual cycle length variability in healthy women. DESIGN: Prospective cross-sectional study. PATIENTS: Two hundred healthy women aged 21-45. MEASUREMENTS: A questionnaire was administered to determine lifestyle factors. Ovarian parameters, metabolic parameters, pituitary hormones, sex steroids and antimüllerian hormone (AMH) were measured. RESULTS: Women with long (≥35 days) and normal (25-34 days) menstrual cycles had >5-fold and >2-fold higher serum AMH levels, respectively, compared to those with short cycles (<25 days). Menstrual cycle length was associated with age but not lifestyle factors. Only one factor group (AMH, antral follicle count [AFC], ovarian volume, testosterone and LH) was significantly associated with menstrual cycle length. Within this factor group, only the ovarian parameters (AMH, AFC, ovarian volume) predicted menstrual cycle length. Each SD increase in AMH (32·9 pmol/l) and ovarian volume (2·29 cm(3) ) was associated with 2·80-fold (95% CI: 1·67-4·69) and 1·62-fold (95% CI: 1·08-2·43) increased risks, respectively, for longer menstrual cycles. CONCLUSIONS: AMH, AFC and ovarian volume are positively associated with menstrual cycle length in healthy women. Our identification of AMH as an independent predictor of menstrual cycle length puts forth a new notion of utilizing menstrual cycle length to predict possible AMH-dependent/-associated outcomes. In addition, this novel relationship may facilitate the interpretation of AMH levels and its clinico-pathological significance across different centres.

[Accuracy of prenatal diagnosis of congenital heart defects by fetal echocardiography: a 7-year experience in a Chinese tertiary obstetric center].

OBJECTIVE: To evaluate the prenatal diagnostic accuracy of fetal echocardiography for congenital heart defects. METHODS: Fetal echocardiographic databases from 2001 to 2007 were searched for patients with a prenatal diagnosis of congenital heart defect, medical records were obtained and the prenatal echocardiographic findings were correlated with postnatal echocardiography results or autopsy findings, if the pregnancy was terminated or the fetus died in utero. RESULTS: Prenatal diagnosis of congenital heart defects was made in 113 pregnancies at a mean gestational age of 26.8 weeks. Pathology or postnatal echocardiography was available in 79 cases (70%) and the accuracy of prenatal diagnosis was 86% (68/79). Prenatal diagnosis was accurate in 24 of 31 patients (77%) with conotruncal malformations, 26 of 27 patients (96%) with septal defects, 9 of 10 patients (90%) with valve abnormalities, and 5 of 6 patients (83%) with univentricular hearts. There were 4 false-positives and the positive predictive value was 95% (75/79). CONCLUSION: Fetal echocardiography is a reliable tool for prenatal diagnosis of congenital heart defects despite limitations for correctly diagnosing some specific fetal heart defects.

[Fetal echocardiography in diagnosing congenital heart disease prenatally: a multicenter clinical study].

OBJECTIVE: To evaluate the detection and accuracy of fetal echocardiography for congenital heart defects among high-risk populations. METHODS: A prospective observational study of prenatal diagnosis of congenital heart disease was conducted in two tertiary obstetrics and gynecology hospitals between January 2003 and December 2004. Consecutive fetuses at risk of congenital heart disease underwent detailed fetal echocardiography during the study period. B-mode and colour/pulsed Doppler flow imaging were used in all cases. Follow-up was sought for all pregnancies. Indications for referral, maternal and gestational age at diagnosis, as well as prenatal and postnatal diagnosis were recorded prospectively. By comparing prenatal and postnatal diagnoses, sensitivity, specificity, and predictive values were estimated. RESULTS: A series of 2063 high-risk fetuses underwent detailed fetal echocardiography during the study period. The mean gestational age at examination was 26.5 weeks, ranging from 16 to 42 weeks. The most common indications for fetal echocardiography were advanced maternal age (31.7%), fetal arrhythmias (13.5%) and maternal infections (10.4%). Forty-three cases of fetal congenital heart disease were detected. The mean gestational age at prenatal diagnosis was 27.3 weeks ranging from 16 to 40 weeks. There were 3 false-negatives and 1 false-positive. The sensitivity, specificity, positive and negative predictive values were 92.1%, 99.9%, 97.2%, and 99.8%, respectively. Diagnostic accuracy was 86.1%. A cardiac defect suspected on routine prenatal sonography accounted for the highest proportion of abnormal cases (67.4%). As for pregnancy outcome, there were 24 (52.1%) terminations; 2.2% died in utero, 13% postnatally, and 28.3% survived. CONCLUSIONS: (1) Fetal congenital heart disease can be identified reliably by prenatal echocardiography. (2) Possible congenital heart disease or suspected heart defect noted on a screening obstetric sonogram is an important indication for fetal echocardiography. (3) A sequential segmental approach is critical for correct evaluation of the cardiac malformation. (4) The outcome of the patients with congenital heart disease is poor and a multidisciplinary approach is needed to the parental counseling and perinatal management planning.