Application of a Standardized Treatment Paradigm as a Strategy to Achieve Optimal Onco-Functional Balance in Glioma Surgery.

BACKGROUND: Gliomas, characterized by their invasive persistence and tendency to affect critical brain regions, pose a challenge in surgical resection due to the risk of neurological deficits. This study focuses on a personalized approach to achieving an optimal onco-functional balance in glioma resections, emphasizing maximal tumor removal while preserving the quality of life. METHODS: A retrospective analysis of 57 awake surgical resections of gliomas at the National University Hospital, Singapore, was conducted. The inclusion criteria were based on diagnosis, functional boundaries determined by direct electrical stimulation, preoperative Karnofsky Performance Status score, and absence of multifocal disease on MRI. The treatment approach included comprehensive neuropsychological evaluation, determination of suitability for awake surgery, and standard asleep-awake-asleep anesthesia protocol. Tumor resection techniques and postoperative care were systematically followed. RESULTS: The study included 53 patients (55.5% male, average age 39 years), predominantly right-handed. Over half reported seizures as their chief complaint. Tumors were mostly low-grade gliomas. Positive mapping of the primary motor cortex was conducted in all cases, with awake surgery completed in 77.2% of cases. New neurological deficits were observed in 26.3% of patients at 1 month after operation; most showed significant improvement at 6 months. CONCLUSION: The standardized treatment paradigm effectively achieved an optimal onco-functional balance in glioma patients. While some patients experienced neurological deficits postoperatively, the majority recovered to their preoperative baseline within 3 months. The approach prioritizes patient empowerment and customized utilization of functional mapping techniques, considering the challenge of preserving diverse languages in a multilingual patient population.

Assessment of socioeconomic and racial differences in patients undergoing concurrent gynecologic oncology and urogynecology surgeries: a National Inpatient Sample (NIS) database study.

OBJECTIVE: To assess social determinants of health impacting patients undergoing gynecologic oncology versus combined gynecologic oncology and urogynecology surgeries. METHODS: We identified patients who underwent gynecologic oncology surgeries from 2016 to 2019 in the National Inpatient Sample using the International Classification of Diseases-10 codes. Demographics, including race and insurance status, were compared for patients who underwent gynecologic oncology procedures only (Oncologic) and those who underwent concurrent incontinence or pelvic organ prolapse procedures (Urogynecologic-Oncologic). A logistic regression model assessed variables of interest after adjustment for other relevant variables. RESULTS: From 2016 to 2019 the National Inpatient Sample database contained 389 (1.14%) Urogynecologic-Oncologic cases and 33 796 (98.9%) Oncologic cases. Urogynecologic-Oncologic patients were less likely to be white (62.1% vs 68.8%, p=0.02) and were older (median 67 vs 62 years, p<0.001) than Oncologic patients. The Urogynecologic-Oncologic cohort was less likely to have private insurance as their primary insurance (31.9% vs 38.9%, p=0.01) and was more likely to have Medicare (52.2% vs 42.8%, p=0.01). After multivariable analysis, black (adjusted odds ratio (aOR) 1.41, 95% CI 1.05 to 1.89, p=0.02) and Hispanic patients (aOR 1.53, 95% CI 1.11 to 2.10, p=0.02) remained more likely to undergo Urogynecologic-Oncologic surgeries but the primary expected payer no longer differed significantly between the two groups (p=0.95). Age at admission, patient residence, and teaching location remained significantly different between the groups. CONCLUSIONS: In this analysis of a large inpatient database we identified notable racial and geographical differences between the cohorts of patients who underwent Urogynecologic-Oncologic and Oncologic procedures.

Low serum creatinine levels are associated with major post-operative complications in patients undergoing surgery with gynecologic oncologists.

OBJECTIVE: Serum creatinine is a byproduct of muscle metabolism, and low creatinine is postulated to be associated with diminished muscle mass. This study examined the association between low pre-operative serum creatinine and post-operative outcomes. METHODS: This retrospective cohort study utilized the 2014-2021 National Surgical Quality Improvement Program to identify patients undergoing surgery with gynecologic oncologists. Patients with missing pre-operative creatinine, end-stage renal disease, sepsis, septic shock, dialysis, or pregnancy were excluded. Pre-operative creatinine was categorized into markedly low (≤0.44 mg/dL), mildly low (0.45-0.64 mg/dL), normal (0.65-0.84 mg/dL), and four categories of elevated levels (0.85-1.04, 1.05-1.24, 1.25-1.44, and ≥1.45 mg/dL). Outcomes included major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, and thromboembolic complications. Also examined were 30-day readmissions, reoperations, and mortality. Logistic regressions assessed the association between creatinine and complications, with stratification by albumin and sensitivity analysis with propensity score matching. RESULTS: Among 84 786 patients, 0.8% had markedly low, 19.6% mildly low, and 50.2% normal creatinine; the remainder had elevated creatinine. As creatinine decreased, the risks of major complications increased in a dose-dependent manner on univariable and multivariable analyses. A total of 9.6% (n=63) markedly low patients experienced major complications, second to creatinine ≥1.45 mg/dL (9.9%, n=141). On multivariable models, both markedly and mildly low creatinine were associated with higher odds of major complications (OR 1.715, 95% CI 1.299 to 2.264 and OR 1.093, 95% CI 1.001 to 1.193) and infections (OR 1.575, 95% CI 1.118 to 2.218 and OR 1.165, 95% CI 1.048 to 1.296) versus normal. Markedly low creatinine had similar ORs to creatinine ≥1.45 mg/dL and was further associated with higher odds of cardiovascular and pulmonary complications (OR 2.301, 95% CI 1.300 to 4.071), readmissions (OR 1.403, 95% CI 1.045 to 1.884), and mortality (OR 2.718, 95% CI 1.050 to 7.031). After albumin stratification, associations persisted for markedly low creatinine. Propensity-weighted analyses demonstrated congruent findings. CONCLUSIONS: Low creatinine levels are associated with major post-operative complications in gynecologic oncology in a dose-dependent manner. Low creatinine can offer useful information for pre-operative risk stratification, surgical counseling, and peri-operative management.

Spontaneous rectus sheath hematoma revealed by abdominal pain during pregnancy: A case report.

INTRODUCTION AND IMPORTANCE: Rectus sheath hematoma (RSH) is an uncommon but significant cause of acute abdominal pain in pregnancy, challenging in both diagnosis and treatment. It often arises from ruptured epigastric vessels and is associated with factors like anticoagulation therapy and previous abdominal surgery. Misdiagnosis, due to nonspecific symptoms, frequently leads to unnecessary surgeries, posing substantial risks to maternal and fetal health. CASE PRESENTATION: We present a case of a 32-year-old multiparous woman at 31 weeks of gestation, experiencing right-sided abdominal pain and irregular contractions. With a history of four full-term deliveries and no recent trauma, her examination showed hemodynamic stability but featured pain upon movement and a notable blue discoloration in the left abdominal area. Moderate anemia was observed in lab tests. The diagnosis of RSH was confirmed via ultrasound and MRI. The treatment approach shifted from conservative to surgical due to deteriorating symptoms and falling hemoglobin levels. CLINICAL DISCUSSION: This case highlights the rarity and seriousness of RSH in pregnancy. Its non-specific symptoms complicate differential diagnosis, underscoring the need for prompt and precise diagnosis to avoid unwarranted surgical interventions. While conservative management is preferred in stable cases, surgical action is required in situations of instability or hematoma growth. CONCLUSION: RSH is a critical consideration in pregnant patients with acute abdominal pain. Early detection and tailored management are essential to mitigate surgical risks and ensure the safety of mother and child. This case reinforces the importance of vigilant and systematic patient evaluation to improve outcomes and minimize unnecessary surgical procedures.

Long-term functional outcomes and surgical retreatment after thulium laser enucleation of the prostate: A 10-year follow-up study.

BACKGROUND: To evaluate the 10-year functional outcomes (primary) and frequency and predictors of BPH surgical retreatment (secondary) after ThuLEP. MATERIALS AND METHODS: A single-center retrospective analysis of consecutive patients undergoing ThuLEP between 2010 and 2013 was performed. Inclusion criteria were: age ≥ 40 years, prostate volume (PV) ≥ 80 mL, International Prostate Symptom Score (IPSS)-Total score ≥ 8 points. IPSS-Total score was the primary outcome, and BPH surgical retreatment rate was the secondary outcome. Paired t-test, McNemar test, and Wilcoxon signed-rank test were used to compare variables. Logistic regression analysis was performed to evaluate predictors of surgical retreatment. RESULTS: A total of 410 patients with a mean ±SD age of 63.9 ± 9.7 years and a PV of 115.6 ± 28.6 mL were included. Mean ±SD follow-up was 108.2 ± 29.6 months. IPSS-Total score was significantly improved at 1 year compared to baseline (23.3 ± 4.7 vs. 10.3 ± 3.8; p<0.001). It was similar after 5 years (10.5 ± 3.6 vs. 10.7 ± 5.0; p=0.161), with a significant worsening at 10 years (10.3 ±4.8 vs. 13.8 ±4.5; p=0.042) but remaining statistically and clinically better than baseline (13.8 ±4.5 vs. 22.1 ±4.3; p<0.001). After 10 years, 21 (5.9%) patients had undergone BPH reoperation. Baseline PV (adjusted OR 1.27, 95% CI 1.09-1.41; p<0.001) and time from BPH surgery (adjusted OR 1.32, 95% CI 1.15-1.43; p<0.001) were predictors of BPH surgical retreatment. CONCLUSIONS: ThuLEP is associated with optimal functional outcomes and a low frequency of BPH surgical retreatment in the long-term. Baseline PV and time from surgery were predictors of BPH reoperation.

Demographic review of aesthetic surgery for patients with facial palsy.

BACKGROUND: This study analyzed the demographic characteristics of patients with facial palsy who were treated using either dynamic or static procedures. This study aimed to compare the frequency of procedure implementation and age distribution between the two groups. METHODS: This study retrospectively analyzed the medical records of patients treated for facial palsy at a single institution from 2014 to 2022. Among cases included in our study, dynamic procedures involved cross-facial nerve graft and latissimus dorsi or gracilis muscle flap transfer. Static procedures included gold weight insertion, canthopexy, browlift, and thread lift/static slings. RESULTS: Among the 31 patients included in our study, eight (25.8%) incorporated dynamic techniques, and the average age of patients was 44.75 years (range, 24-68 years) with a male to female ratio of 1:4. The remaining 23 patients (74.2%) underwent a static procedure, of which the average age was 59.17 years (range, 23-81 years) which was statistically significantly higher than the average age of 44.75 of dynamic patients (p= 0.013). Regarding the timing of treatment after diagnosis, no patient underwent dynamic procedures more than 20 years after initial diagnosis. A greater diversity in the timing of treatment was observed in the static group. All patients who underwent dynamic procedures were treated using static procedures during the study period. CONCLUSION: Because aesthetics-based static techniques are typically quick outpatient procedures that can be performed under local anesthesia, our study shows that these are often preferred treatments for all age groups, especially for debilitated or older patients. Further research is required to investigate the long-term functional outcomes of these surgical techniques in a wider population of patients.

Minimally Invasive Tibiotalocalcaneal Arthrodesis with Blocked Retrograde Intramedullary Nail - Report of Three Cases.

Ankle osteoarthritis (AOA) is associated with pain and variable functional limitation, demanding clinical treatment and possible surgical indication when conservative measures are ineffective - arthrodesis has been the procedure of choice, because it reduces pain, restores joint alignment and makes the segment stable, preserving gait. The present study reports 3 cases (3 ankles) of male patients between 49 and 63 years old, with secondary AOA, preoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS AHS) of 27 to 39 points, treated by minimally invasive tibiotalocalcaneal arthrodesis using blocked retrograde intramedullary nail. Hospital stay was of 1 day, and the patients were authorized for immediate loading with removable ambulation orthotics, as tolerated. The physical therapy treatment, introduced since hospitalization, was maintained, prioritizing gait training, strength gain, and proprioception. Clinical and radiographic follow-up was performed at weeks 1, 2, 6, 12 and 24. After evidence of consolidation (between the 6 th and 10 th weeks), the orthotics were removed. One patient complained of pain in the immediate postoperative period and, at the end of the 1 st year, only one patient presented pain during rehabilitation, which was completely resolved with analgesics. Currently, the patients do not present complaints, returning to activities without restrictions - one of them, to the practice of soccer and rappelling. The postoperative AOFAS AHS was from 68 to 86 points.

Assessment of sentinel Lymph node mapping with different volumes of Indocyanine green in early-stage ENdometrial cancer: the ALIEN study.

OBJECTIVE: To evaluate the impact of different volumes of indocyanine green (ICG) on the detection rate and bilateral mapping of sentinel lymph nodes in patients with apparent uterine-confined endometrial cancer. METHODS: All patients who underwent surgical staging with sentinel node mapping in six reference centers were included. Two different protocols of ICG intracervical injection were used: (1) 2 mL group: total volume of 2 mL injected superficially; (2) 4 mL group: total volume of 4 mL, 2 mL deeply and 2 mL superficially. Logistic regression was used to analyze factors that could influence dye migration and detection rates. A sensitivity analysis was carried out to determine how independent variables could affect the sentinel node detection rate. RESULTS: Of 442 eligible patients, 352 were analyzed (172 in the 2 mL group and 180 in the 4 mL group). The bilateral detection rates of the 2 mL and 4 mL groups were 84.9% and 86.1%, respectively (p=0.76). The overall detection rate was higher with a volume of 4 mL than with 2 mL (97.8% vs 92.4%, respectively; p=0.024). In the univariate analysis the rate of bilateral mapping fell from 87.5% to 73.5% when the International Federation of Gynecology and Obstetrics (FIGO) 2009 tumor stage was >IB (p=0.018). In the multivariate analysis, for both overall and bilateral detection rates a statistically significant difference emerged for the volume of ICG injected and FIGO 2009 stage >IB. Increasing body mass index was associated with worse overall detection rates on univariate analysis (p=0.0006), and significantly decreased from 97% to 91% when the body mass index exceeded 30 kg/m2 (p=0.05). CONCLUSIONS: In patients with early-stage endometrial cancer, a volume of 2 mL ICG does not seem to compromise the bilateral detection of sentinel lymph nodes. In women with obesity and FIGO 2009 stage >IB, a 4 mL injection should be preferred.

[Injuries of the ankle ligaments]. / Bandverletzungen des oberen Sprunggelenks.

Lateral ligament injuries are the most common injuries of the ankle joint and are usually treated with early weight bearing after a short period of immobilization. If the clinical presentation is suspicious, additional injuries to the deltoid ligament complex and the syndesmosis should be considered. The indications for additional diagnostics should be generously applied. Injuries to the deltoid ligament usually occur as part of a complex ankle injury and should also be addressed in the surgical treatment of accompanying injuries. Chronic instability in this area necessitates complex bony and soft tissue procedures. Syndesmotic injuries with insufficiency of the capsule-ligament apparatus are frequent in ankle fractures and are stabilized during fracture treatment. Isolated syndesmotic instability should also be surgically treated as chronic injuries are usually associated with poor clinical results and early osteoarthritis.

Surgical Outcome of Postinfarction Left Ventricular Free Wall Rupture.

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a rare and fatal complication after acute myocardial infarction. Early recognition and aggressive treatment are recommended. METHODS: Between August 1999 and February 2023, 11 patients aged between 64 and 79 years developed LVFWR after acute myocardial infarction (mean interval, 3.5 days). Three patients had active bleeding (blowout-type LVFWR), and the other 8 patients experienced the oozing or sealed state. Eight patients were treated using a sutureless technique with Teflon felt and glue, 2 patients were treated using the primary suture closure technique, and 1 was treated using both the primary suture and the sutureless technique with Teflon felt and glue. RESULTS: One patient died in the operating room as a result of bleeding. Cardiovascular stability and hemostasis were achieved in the other 10 patients. There were 3 early deaths (all 3 cases as a result of area bleeding; 1 was treated with primary suture, 2 with sutureless glue). Three patients received percutaneous coronary intervention before discharge. All 8 remaining patients survived and were discharged. Three patients were lost to follow-up. The follow-up period ranged from 2 to 97 months, with 4 patients exhibiting New York Heart Association class I symptoms and 1 exhibiting New York Heart Association class II symptoms. CONCLUSION: Optimal surgical treatment for postinfarction LVFWR remains controversial. The sutureless technique may be a promising strategy for treating postinfarction LVFWR.

Recommendations from Annals of Surgical Oncology： Clinical guidelines for extrahepatic cholangiocarcinoma and gallbladder carcinoma / 临床肝胆病杂志

Biliary tract carcinoma （BTC） is a type of gastrointestinal tumor with a low incidence rate and a strong invasive ability， mainly including intrahepatic cholangiocarcinoma （ICC）， extrahepatic cholangiocarcinoma （ECC）， and gallbladder carcinoma （GC）， often accompanied by local progression or distant metastasis. Surgery is often the preferred treatment method for patients with local resectable tumor； however， there is still a high risk of recurrence after radical surgery. Therefore， multiple treatment modalities are often required for BTC patients， including surgical resection， systemic treatment （such as targeted therapy， chemotherapy， and immunotherapy）， and/or a combination of local treatment methods. With the development of the field of BTC， it is critical for surgical oncologists to understand and master the latest surgical strategies and the best patient selection and management systems. In view of the complexity of treatment and the continuous development of diagnosis and treatment techniques， Annals of Surgical Oncology， an authoritative American journal of cancer surgery， recently published the practical diagnosis and treatment guidelines for hepatobiliary tumors， including hepatocellular carcinoma （HCC）， ICC， ECC， and GC， aiming to provide more evidence-based evidence for the clinical management and decision-making of patients with hepatobiliary tumors. Due to the limitations of length and different emphases， this article mainly introduces the recommendations for the evaluation points and clinical treatment of ECC and GC in the guidelines， so as to provide a reference for clinical practice.

Situaciones transoperatorias en pacientes pediátricos con fractura supracondílea del húmero

Introducción: Las fracturas supracondíleas del húmero en el niño, por lo general, son tratadas de manera quirúrgica, durante esa intervención se pueden presentar situaciones específicas en este tipo de enfermos. Objetivo: Actualizar y brindar información sobre algunas de las situaciones transoperatorias en pacientes con fractura supracondílea del húmero. Métodos: La búsqueda y análisis de la información se realizó en un periodo de 61 días (primero de septiembre al 31 de octubre de 2022) y se emplearon palabras de búsqueda relacionadas con la investigación. A partir de la información obtenida, se realizó una revisión bibliográfica de un total de 245 artículos publicados en las bases de datos: PubMed, Hinari, SciELO y Medline, mediante el gestor de búsqueda y administrador de referencias EndNote, de ellos, se utilizaron 29 citas seleccionadas para realizar la revisión, 28 de los últimos cinco años. Resultados: Se hace referencia a cuatro de las situaciones transoperatorias más frecuentes en este tipo de fractura. Se mencionan la conminución de la pared medial, como identificar esta situación y su conducta. En relación a las lesiones asociadas, se recomienda primero estabilizar el antebrazo y luego la fractura supracondílea. Para las fracturas inestables en flexión se recomienda la técnica a emplear. Por su parte, la conversión de la reducción cerrada a abierta está justificada en ciertas circunstancias que de forma detallada se describen en el trabajo. Conclusiones: Las fracturas supracondíleas del húmero en el niño son tratadas en su mayoría mediante tratamiento quirúrgico. Durante el transoperatorio se pueden presentar situaciones para las cuales el médico tratante debe estar preparado.

Introduction: Supracondylar fractures of the humerus in children are generally treated surgically, during surgery intervention may occur specific situations in this type of patient. Objective: To update and provide information on some of the intraoperative situations in patients with supracondylar fracture of the humerus. Methods: The search and analysis of the information was carried out in a period of 61 days (September 1st to October 31st, 2022) and search words related to the investigation were used. Based on the information obtained, a bibliographic review of a total of 245 articles published in the PubMed, Hinari, SciELO and Medline databases was carried out using the EndNote search manager and reference administrator, of which 29 selected citations were used to carry out the review, 28 of the last five years. Results: Reference is made to four of the most frequent intraoperative situations in this type of fracture. Comminution of the medial wall, how to identify this situation and its behavior are mentioned. In relation to associated injuries, it is recommended to first stabilize the forearm and then the supracondylar fracture. For unstable fractures in flexion, the technique to be used is recommended. For its part, the conversion from closed to open reduction is justified in certain circumstances that are described in the article. Conclusions: Supracondylar fractures of the humerus in children are mostly treated by surgical treatment. During the trans-operative period situations may arise for which the treating physician must be prepared.