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Intussusception is usually idiopathic, with no pathologic lead point except for the presence of reactive lymphoid hyperplasia, which is probably associated with gastrointestinal infection or a reaction to newly introduced food proteins. Viral infections, such as those caused by non-enteric adenovirus, human herpes virus (HHV)-6, HHV-7, and Epstein-Barr virus, are known etiologic factors of intussusception. Cytomegalovirus (CMV)-associated intussusception has been reported rarely; there have been three case reports in immunocompetent and human immunodeficiency virus–infected infants [1-3]. None of these three case reports described a detailed histologic pattern, except ischemic necrosis of the small intestine due to a prolonged clinical history and delayed surgery. Here, we report a case of a CMV-associated inflammatory polyp with unique gross and microscopic findings as a leading cause of ileoileal intussusception in an 8-week-old healthy female.

Background Conservative management for uncomplicated displaced clavicle fractures is common practice. Delay of surgical fixation may result in less favorable outcomes. Methods A retrospective cohort study was conducted of 60 patients with a closed mid-third clavicle fracture that did not meet current operative or nonoperative guidelines; 20 primary (plate fixation 6 weeks), and 20 matched conservative patients were included. Each patient completed 2 questionnaires, the Disabilities of the Arm, Shoulder, and Hand and the American Shoulder and Elbow Surgeons, as well as visual analog scales for pain, cosmetic satisfaction, and overall satisfaction. In addition, 10 patients from each group underwent clinical review of scapular rotation by the lateral scapular slide test, clinical impingement, range of motion assessment, and radiologic review of clavicle union and length. Results The American Shoulder and Elbow Surgeons patient self-reported questionnaire demonstrated a median score of 5.5 for the delayed group, 2 for the primary group, and 1 for the conservative group ( P = .032). The median Disabilities of the Arm, Shoulder, and Hand score was 7.92 for the delayed group, 3.32 for the primary group, and 1.67 for the conservative group ( P = .212). Six patients in the delayed group had scapular malrotation compared with 2 in the primary group and none in the conservative group ( P = .008). Flexion and external rotation in 90° abduction were decreased in the conservative group ( P = .049 and .041, respectively). Conclusion We support the conservative management of uncomplicated displaced clavicle fractures but recognize that a lower threshold for early surgery should be considered where optimal shoulder function is required.

This article presents the implementation of Lean health care techniques in a surgery department of a Brazilian hospital. The proposed Lean methodology is based on a set of nested improvement cycles that are used to continuously improve the value chain. The results of the implementation showed improvement in cycle time, capacity, and savings in costs. Another important improvement was a significant reduction of 94 percent in the index of delayed surgery due to the lack of materials and a reduction in postsurgery infection.

Background The purpose of the study was to evaluate the relationships between the patients' clinical characteristics and the growth pattern of SRMs, and to investigate the predictive factors of tumor growth rates in patients initially managed with AS. Materials and Methods We retrospectively reviewed data from our prospectively collected database of 70 patients diagnosed with 72 SRMs between 1996 and 2013. Clinical and demographic data, and linear and volumetric growth rates were recorded for each patient. A Pearson correlation test was used to evaluate initial tumor size and linear or volumetric growth rate. Logistic regression models were used to evaluate the predictive factors affecting tumor growth kinetics. Results The mean age was 76 ± 6.8 years, and 47 (67.1%) of patients were male. The mean (± SD) and the median (interquartile range [IQR]) tumor size at presentation were 2.1 ± 1.3 and 2.7 (1.8-3.7) cm, respectively. The mean (± SD) and the median (IQR) linear growth rate were 0.5 ± 0.3 and 0.6 (0.4-1.5) cm per year, respectively. Patients treated with delayed surgery experienced a significantly greater mean linear growth rate (1.4 vs. 0.3 cm per year) than those observed in the AS group ( P P = .04) and symptomatic presentation (HR, 1.85; P = .02) were found to be significant predictors of tumor growth rates during AS. Conversely, age, Charlson Comorbidity Index, and initial tumor size failed to predict growth kinetics. Conclusion Male sex and symptomatic presentation are associated with faster growth rates in patients managed with AS after long-term follow-up.

Background: In the Phase III ‘GRETA’ trial 474 women aged ≥70 years with early breast cancer were randomly assigned to surgery plus tamoxifen for 5 years or tamoxifen alone for 5 years. This is a long-term update. Patients & methods: Focusing on patients still alive in 2003, outcome end points has been recalculated. Results: Median distant metastases disease-free survival is longer with tamoxifen alone for 5 years; (48.8 vs 37.9 months; p = 0.009). No difference was found in distant metastases rate, disease-free survival, breast cancer and overall survival. Conclusion: Primary endocrine treatment until the the best response, followed by minimal surgery and prosecution endocrine treatment for 5–10 years is a suitable option for elderly breast cancer patients. Delayed surgery does not prejudice overall survival.

Introduction: The incidence of peptic ulcer disease has declined since the introduction of medical therapy, but the rate of perforated peptic ulcer and associated mortality has remained relatively constant. Delay to definitive treatment is known to adversely affect survival. Methods: The Australian and New Zealand Audit of Surgical Mortality (ANZASM) retrospectively collects data on patients who died following surgery. To determine which patient characteristics are associated with delayed (not on the day of admission) surgical treatment of a perforated peptic ulcer, all patients who died in Queensland were identified from the ANZASM database. Results: There were 39 deaths between 2007 and 2013 with a median age was 76 years. The median number of comorbidities was three and American Society of Anaesthesiologists (ASA) class Original Research Article Wysocki et al.; BJMMR, 8(10): 842-847, 2015; Article no.BJMMR.2015.514 843 was 4. Twenty nine patients had operative intervention on the day of admission and 10 underwent surgery later. Those with delayed surgery had a greater number of comorbidities (4 vs. 3; p = 0.016) but did not differ with respect to other demographics compared to those who underwent repair on the day of admission. The reviewing surgeon found no management issues in two thirds of patients. Conclusion: Queensland patients with an increasing number of comorbidities were more likely to have delayed surgical intervention for a perforated peptic ulcer. Surgical delay is a known determinant of survival in patients with a perforated peptic ulcer and surgeons must be especially vigilant in multiply comorbid patients in making the diagnosis and expediting repair.

Aims: This study was done with the aim to compare the clinical outcome and patients’ quality of life between early versus delayed surgically treated patients of acute subaxial cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute subaxial cervical spinal cord trauma is safe and is associated with improved outcome as compared to delayed surgical decompression. Materials and Methods: A total of 69 patients were recruited and divided into early decompression surgery Group A (operated within 48 h of trauma; n = 23) and late/delayed decompression surgery Group B (operated between 48 h and 7 days of trauma; n = 46). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion. Results: The early surgery group spent lesser days in the intensive care unit and hospital (Group A 28.6 vs. Group B 35 days) had lesser postoperative complications (Group A 43% vs. Group B 61%) and a reduced mortality (Group A 30% vs. Group B 45%). In Group A, 38% patients had 1 American Spinal Injury Association (ASIA) grade improvement while 31% experienced >2 ASIA grade improvement. In Group B, the neurological improvement was 27% and 32%, respectively (P = 0.7). There was a significant improvement in the postoperative quality of life scores in both groups. Conclusion: Early surgery in patients with acute subaxial cervical spine injury should be considered strongly in view of the lesser complications, early discharge, and reduced mortality.

To determine how often preoperative testing is requested for geriatric hip fracture patients, to assess the extent to which preoperative testing is associated with delayed surgery, and to measure the frequency with which preoperative testing changes patient management.Retrospective.Academic health system.Two hundred fifty consecutive geriatric hip fracture patients admitted through the emergency department and underwent surgery.Hip fracture surgery.The patients were categorized according to whether additional preoperative tests were requested. For each patient, the times of presentation and surgery were recorded, yielding a "time-to-surgery interval." The results of any tests, the actions resulting from testing, and the length of hospital stay were also noted.Additional preoperative testing was performed for 67 patients (27%). For those patients, the mean time-to-surgery was 73 hours. For the 183 patients who had no testing, the mean time-to-surgery was 37 hours. Moreover, 42 of the 67 patients with testing (63%) had time-to-surgery greater than 48 hours, compared with only 37 of the 183 (20%) patients without testing. The mean length of stay for tested patients was 12.0 days compared with 9.0 days for nontested patients. In only 2 of the 67 tested patients was further care offered based on the test result.Testing was associated with greater time-to-surgery and length of stay. Furthermore, testing rarely influenced management. Patients might be able to have surgery more expeditiously and leave the hospital earlier if testing were deferred.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background Early orchidopexy (OP) around the age of 1 year is recommended in boys with congenital undescended testis (UDT) worldwide since decades. Former retrospectives studies did not distinguish congenital from acquired UDT with a consecutive negative bias concerning the age at surgery. Methods In a retrospective analysis, data of all boys who underwent OP in eight pediatric surgery institutions from 2009 to 2015 were analyzed. Congenital or acquired UDT were differentiated. Patients were categorized into 3 groups of age at surgery: (1) 24 months. Data of one institution were analyzed in detail: exact age of first referral, exact age at surgery, intraoperative findings. Results Out of 4448 boys, 3270 boys had congenital UDT. In 81% (2656 cases) surgery was performed beyond the age of 1 year, in 54.4% (1780) beyond the age of 2 years. chi-Square statistics showed a higher rate of early operations in hospitals compared to outpatient services and in Germany compared to Switzerland. In 694 congenital detailed cases, median age at referral was 13 months [range 0–196], median age at surgery was 15 months [range 0–202]. Conclusion Delayed referral is the main reason for guideline non-conform delayed surgery in UDT. Type of Study Clinical Research paper. Level of evidence Level III: Treatment Study.

Clavicle fractures account for 2.6–5% of all fractures treated by orthopedic practitioners (Clin Orthop Relat Res (300):127–32, 1994; J Shoulder Elb Surg 11(5):452–6, 2002). Appropriate radiographic evaluation of clavicle fractures is paramount in developing a plan of care. Today, widely accepted indications for nonoperative management in adults are nondisplaced or minimally displaced midshaft clavicle fractures and patients who are poor surgical candidates based on medical comorbidities. The optimal treatment of fractures that lie outside these indications is more controversial. All patient factors including baseline activity level, handedness, fracture pattern, patient expectation, mechanism of injury, and risk factors for nonunion should be evaluated and discussed with the patient. Nonoperative management relies on immobilization for 2–6 weeks with either sling or figure of eight brace while monitoring radiographs. Patients should be counseled that, in most cases, nonoperative management will provide a successful outcome; however, some may require delayed surgery for symptomatic nonunion or malunion. The patient and physician must discuss treatment options and come to a mutually acceptable treatment plan.

The full publication in Lancet Oncology of the Stockholm III trial helps us to understand that short-course radiotherapy in patients with localised rectal cancer could also be followed by delayed surgery.1 During more than 14 years, more than 800 patients with rectal cancer not showing unresectable features were randomised in a two-arm versus three-arm study with a non-inferiority design. Patients could be randomised to short-course radiotherapy (5×5 Gy) and immediate (within a week) versus delayed (4–8 weeks) surgery. In the three-arm randomisation patients could also be allocated to a long course of concurrent chemoradiation (25×2 Gy), with surgery performed 6–8 weeks thereafter. Time to local recurrence was established as the primary endpoint. Interestingly, short-course radiotherapy followed by delayed surgery was proven to have less acute toxicity and a lower postoperative complication rate compared with immediate surgery. Oncological results were similar among the three arms. The authors conclude that short-course radiotherapy with surgery delayed for 4–8 weeks might have certain advantages over immediate surgery in rectal cancer treatment. Another interesting fact …

Background The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a ‘delayed’ operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. Methods Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost–utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. Results Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0–120 000). Conclusion Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.

Background:Head and neck space infections present with a potential mortality rate of 40–50 per cent. This paper proposes an algorithm-based management of head and neck space infection to prevent life-threatening events.Methods:A total of 225 patients with head and neck space infection were prospectively analysed at our institution. An experimental scoring system determined the level of clinical risk for the development of major complications. Accordingly, patients were classified into three risk groups: low-, intermediate- and high-risk.Results:Only intermediate- and high-risk patients were hospitalised. Intermediate-risk patients received intravenous medical therapy with daily re-evaluation; 18 of them required delayed surgery. Of the high-risk patients, three required immediate surgical treatment and five received delayed surgery, while in five cases medical therapy was the only treatment received. Low-risk patients were treated in an out-patient setting.Conclusion:The algorithm-based management of head and neck space infection was successful in enabling the avoidance of lethal complications onset.

Anterior cruciate ligament (ACL) reconstruction in most cases is an elective surgery with many potential complications. Early (non-emergent) surgery may increase the risk of certain complications including significant postoperative stiffness with loss of motion. Delaying surgery by a few weeks to allow the acutely injured knee to regain motion and gain quad control decreases the risk for these adverse effects. However, delayed ACL reconstruction with the intent of returning to normal activities months after the initial injury may lead to an increased risk of injury to cartilage and menisci. By choosing a delayed surgical treatment pathway, we are not intending to return the patient to sports; rather, we plan to get them through the acute inflammatory phase prior to reconstruction. We know by experience and by numerous well-designed studies that returning a patient with a potentially unstable knee to at risk activities including sports and certain occupations can lead to further injuries with irreversible damage.

Aim: To examine clinical and surgical performances of cases with placental polyps in which uterine preservation surgery was conducted. Methods: During the period September 2002 to April 2009, we examined eight cases (hysteroscopic resection, six cases; laparotomy, one case; dilatation and curettage, one case) diagnosed with placental polyp that had been treated with polyp extraction surgery. Imaging evaluation was done using magnetic resonance imaging and 2-D ultrasound. Results: Three of the eight cases (37.5%) had been first-time pregnancies. Most of our cases experienced minimal surgical manipulation after medical abortion. Among them, six cases (75%) were mid-term medical abortions, one case (12.5%) received no treatment after spontaneous abortion, and one case (12.5%) had postsurgical abortion (dilatation and curettage). All cases showed variable amount of blood flow in the internal mass and myometrium by color Doppler ultrasound. Magnetic resonance imaging angiography showed contrast effects in the intrauterine cavity and myometrium in selected cases. The average duration from diagnosis to surgery was 32 days (range, 11-105). Color Doppler revealed a reduction in blood flow in five cases during the waiting period until surgery with an average blood loss of 10 g (range, 0-20) during surgery. Conclusion: Use of color Doppler ultrasound may be useful in diagnosing placental polyp. Although hysteroscopic resection of placental polyp is effective in patients hoping for uterine preservation, delaying timing of surgery may reduce blood loss during operative procedure., 長崎大学学位論文 学位記番号:博(医歯薬)乙第35号 学位授与年月日:平成26年12月3日, Author: Koichi Hiraki, Khaleque Newaz Khan, Michio Kitajima, Akira Fujishita, Hideaki Masuzaki, Citation: The Journal of Obstetrics and Gynaecology Research, 40(1), pp.89-95; 2014

Introduction: The purpose of this study was to determine the types of incidents that occurred in the iMRI OT over a nineteen-month period in our institution. We aim to prevent any future avoidable incidents from happening in this potentially hazardous environment. Methods: This is a single centre prospective non-anonymous observational study conducted from February 2009 to September 2010 on surgeries performed in the iMRI OT. Safety incidents specific to the iMRI OT such as violation of safety protocols and equipment failures were reported as well as any other safety incidents resulting in potential or actual adverse safety outcomes. The outcomes of the incidents were included and the data analysed at the end of the study period. Results: Of 271 cases that were operated in the iMRI OT, 43 incidents were reported by the staff involved in the care of the patient. Of the 43 incidents, 14 incidents (32.6%) were classified as staff/personnel error and were preventable. Incidents resulted in either delayed surgery or cancellation of the surgery. There were no major adverse incidents that led to patient harm. Conclusion: Many of the incidents were preventable and measures have been instituted to prevent the recurrence of such incidents. Staff training, safety protocols and stringent maintenance of equipment are paramount to safe and efficient use of the iMRI operating theatre.

To analyze the changes in the curve extent, pattern and the fusion level in adolescent idiopathic scoliosis (AIS) patients who undergo delayed surgery instead of early surgery. Thirty-five immature AIS patients whose radiographs demonstrated an initial primary curve of more than 40° with a subsequent increase of 10° before attaining skeletal maturity with brace were enrolled. The initial and the final radiographs taken before surgery were compared to assess the changes in curve extent, pattern and the fusion levels as recommended by King’s, Lenke’s and Suk’s guidelines. The average age of 35 AIS patients was 12.7 ± 1.6 years. The time interval between initial and final radiography was 39.3 ± 20.2 months and the degree of progress of the primary curve was 13 ± 9.7°. Fusion levels changed in 33 (94.2 %), 33 (94.2 %) and 32 (91.4 %) patients according to King’s, Lenke’s and Suk’s guidelines, respectively. Curve pattern was changed in 2 (5.7 %), 12 (34.3 %) and 10 (28.6) patients by King’s, Lenke’s and Suk’s guidelines. The mean number of levels requiring fusion increased from 9.4 ± 2.1 at initial visit to 11.1 ± 1.8 at the final follow-up using King’s guidelines, 9.7 ± 2.2–11.6 ± 2.0 as per Lenke’s guidelines and 9.1 ± 2.0–11.5 ± 2.3 when fusion was planned using Suk’s guidelines (p

Introduction: Acute biliary pancreatitis is a serious complication of biliarycalculous disease and is associated with significant morbidity and mortality. Incidence is moreoften in females and cause is the gall stones in majority of the cases. Definitive treatment ischolecystectomy and with the advancement of minimal invasive surgery, laparoscopiccholecystectomy has been considered as a gold standard for the management of acute BiliaryPancreatitis. The optimal timing when to perform laparoscopic cholecystectomy is still underdebate. Many surgeons recommend early surgery whereas others are in favor of delayedsurgery. This study is carried out to compare the timing of laparoscopic cholecystectomy in casesof acute biliary pancreatitis. Objective: To compare the frequency of conversion fromlaparoscopic to open cholecystectomy in early versus delayed laparoscopic cholecystectomy inmild to moderate acute biliary pancreatitis. Study design: Randomised Control trial (RCT).Setting: Department of surgery, Holy Family Hospital, Rawalpindi. Duration: Six months, fromJanuary 2010 to June 2012. Material and methods: 306 patients, diagnosed as mild tomoderate acute Biliary Pancreatitis were randomly allocated into two groups for laparoscopiccholecystectomy. Those who were operated within two weeks of index hospital admission werelabeled as Early laparoscopic cholecystectomy (EC) group whereas those undergoing surgeryafter 02 weeks of index hospital admission were considered as Delayed laparoscopiccholecystectomy group(DC). Conversion rate from laparoscopic to open cholecystectomy wascompared in two groups. Results: Out of 153 patients enrolled as EC group, 138 were female and15 were male patients. Mean age was 39.19 ± 11.25years where as in DC group , there were 134female and 19 male patients in a total of 153 patients, and the mean age was 39.54 ±10.37 years.Conversion from laparoscopic surgery to open cholecystectomy was 8.5%(13 patients) and13.1%(20 patients) in EC and DC groups respectively. The overall conversion rate was 10.8%.There was no statistical significance between conversion rate of the two groups. (p = 0.197)Conclusions: Acute Biliary Pancreatitis should be managed by laparoscopic cholecystectomyregardless of the time elapsed since the start of symptoms. There is no statistical significance ofconversion rate from laparoscopic to open cholecystectomy associated with the timing ofsurgical intervention in the case of acute Biliary Pancreatitis.

A previous study showed promising results for gadofosveset-trisodium as a lymph node magnetic resonance imaging (MRI) contrast agent in rectal cancer. The aim of this study was to prospectively confirm the diagnostic performance of gadofosveset MRI for nodal (re)staging in rectal cancer in a second patient cohort. Seventy-one rectal cancer patients were prospectively included, of whom 13 (group I) underwent a primary staging gadofosveset MRI (1.5-T) followed by surgery (± preoperative 5 × 5 Gy) and 58 (group II) underwent both primary staging and restaging gadofosveset MRI after a long course of chemoradiotherapy followed by surgery. Nodal status was scored as (y)cN0 or (y)cN+ by two independent readers (R1, R2) with different experience levels. Results were correlated with histology on a node-by-node basis. Sensitivity, specificity and area under the receiver operating characteristics curve (AUC) were 94 %, 79 % and 0.89 for the more experienced R1 and 50 %, 83 % and 0.74 for the non-experienced R2. R2’s performance improved considerably after a learning curve, to an AUC of 0.83. Misinterpretations mainly occurred in nodes located in the superior mesorectum, nodes located in between vessels and nodes containing micrometastases. This prospective study confirms the good diagnostic performance of gadofosveset MRI for nodal (re)staging in rectal cancer. • Gadofosveset-enhanced MRI shows high performance for nodal (re)staging in rectal cancer. • Gadofosveset MRI may facilitate better selection of patients for personalised treatment. • Results can be reproduced by non-expert readers. • Experience of 50–60 cases is required to achieve required expertise level. • Main pitfalls are nodes located between vessels and nodes containing micrometastases.

Purpose\ud \ud To establish whether early vitrectomy for epiretinal membrane (ERM) is preferable to delayed surgery.\ud \ud Methods\ud \ud We carried out a retrospective study of 120 eyes from 120 patients with pre-operative visual acuity (VA) of 6/60 or better. Pre-operative logMAR score was considered to act as an appropriate proxy measure for time of surgical procedure, with scores of 0.3 or less considered to represent early surgery, scores of 0.4 or 0.5 considered to represent medium surgery, and scores of 0.6 or more considered to represent late surgery for ERM. Patients were either pseudophakic at the time of vitrectomy or underwent combined phaco-vitrectomy for symptomatic ERM.\ud \ud Results\ud \ud Evaluation of parameter coefficients indicated that controlling for other factors, a delay of the surgical procedure from a state of early to medium corresponded to an increase (ie, disbenefit) of 0.074 units in post-operative logMAR score (95% confidence interval −0.001–0.15). A delay of the surgical procedure from a state of early to late corresponded to an increase (ie, disbenefit) of 0.21 units in post-operative logMAR score (95% confidence interval 0.13–0.29). Mean post-operative VA for early surgery was 0.16, out of which 36.2% of patients had a LogMAR score of 0.1 or better. This is in comparison to 17.2% in late ERM (those with a pre-operative logMAR score of 0.6 or more).\ud \ud Conclusion\ud \ud We conclude that early surgery is associated with a lower (ie, better) post-operative logMAR score. Vitrectomy for early symptomatic ERM, in carefully selected patients, is beneficial in preserving excellent vision and allows quicker visual rehabilitation.

Aim: To examine clinical and surgical performances of cases with placental polyps in which uterine preservation surgery was conducted. Methods: During the period September 2002 to April 2009, we examined eight cases (hysteroscopic resection, six cases; laparotomy, one case; dilatation and curettage, one case) diagnosed with placental polyp that had been treated with polyp extraction surgery. Imaging evaluation was done using magnetic resonance imaging and 2-D ultrasound. Results: Three of the eight cases (37.5%) had been first-time pregnancies. Most of our cases experienced minimal surgical manipulation after medical abortion. Among them, six cases (75%) were mid-term medical abortions, one case (12.5%) received no treatment after spontaneous abortion, and one case (12.5%) had postsurgical abortion (dilatation and curettage). All cases showed variable amount of blood flow in the internal mass and myometrium by color Doppler ultrasound. Magnetic resonance imaging angiography showed contrast effects in the intrauterine cavity and myometrium in selected cases. The average duration from diagnosis to surgery was 32 days (range, 11-105). Color Doppler revealed a reduction in blood flow in five cases during the waiting period until surgery with an average blood loss of 10 g (range, 0-20) during surgery. Conclusion: Use of color Doppler ultrasound may be useful in diagnosing placental polyp. Although hysteroscopic resection of placental polyp is effective in patients hoping for uterine preservation, delaying timing of surgery may reduce blood loss during operative procedure., The Journal of Obstetrics and Gynaecology Research, 40(1), pp.89-95; 2014

Aim: Undescended testis (UDT) is the most common congenital urinary system disease. Delayed treatment increases the risk of infertility or malignancy. The aim of this study was to evaluate the effect of educational status and geographical location of the parents (rural vs. urban) on the timing of surgery in patients with UDT.Material and Methods: The retrospective study included 248 patients that underwent surgery due to UDT between 2014 and 2018. The patients were divided into two groups based on age at surgery: (I) >1 year and (II) ≤1 year. Data regarding the educational status and geographical location of the parents were obtained via telephone interviews. Results: Of the 248 patients, 67% (n=166) of them were aged over 1 year (Group I) and 33% (n=82) of them were aged below 1 year (Group II). Mean age at surgery was 48.98±29.25 months in Group I and 9.68±1.98 months in Group II. The educational status of the parents was higher in the patients aged below 1 year than in patients aged over 1 year. In addition, the patients living in urban areas admitted to the hospital earlier than those living in rural areas. Conclusion: Both the parental educational status and the geographical location of the parents had a significant effect on the timing of surgery in UDT patients. Keywords: Undescended testis; education status; geographical location

The differential diagnosis of cystic adnexal masses includes various pathologies, some placed extragonadally. Herein, we present two different cases of omental ovarian dermoid tumours that were diagnosed using ultrasonography and removed with surgery. The greater part of the omental teratomas appear to have developed from self-amputation of cysts in the ovary, followed by their re-implantation into the omentum. Omental teratomas can be located in the pelvis, where they might be mistaken for an adnexal mass, an upper abdominal mass, or a periumbilical mass. The location of omental teratomas might slightly change from one examination to another. In such cases, preoperative diagnostic imaging methods may not provide adequate information to physicians. Gynecologists should always keep in mind the possibility of intraabdominal ovarian parasitic cystic teratomas in the differential diagnosis of suspicious adnexal masses during surgery. Awareness among gynecologic surgeons of such masses may help prevent misdiagnosis, delayed surgery, or the use of wrong surgical approaches.

Background: Aneurysm surgery is increasing day by day in our country but the exact timing of surgery is still controversial.Objectives: The aim of this study was to determine the results of early and late surgery for aneurismal subarachnoid haemorrhage. The aim of microneurosurgical management of an aneurysm is the total occlusion of the aneurysm sac by clipping at the neck of aneurysm with preservation of flow in the parent artery and preservation of all its perforating arteries with minimal or no brain retraction.Methods: There were 52 patients included in this study among them 3 patients expired soon after the admission before surgery could take place. Hence 49 patients underwent clip surgery from July 2005 to May 2012 for 52 aneurysms because 3 patients harboured multiple aneurysms. Patient’s history, clinical findings, Hunt & Hess grading, Fisher grading of CT scan, preoperative & postoperative CT angiography, postoperative outcome were collected and analyzed.Results: Most of the clipping (57.14%) were done in intermediate stage (4th to 10th days), because patients usually referred from peripheral hospital on 2nd or 3rd day after the acute SAH Those who was admitted early and H&H status good, was fit to do early surgery (within 3rd day), (28.57%). Overall outcome was assessed at 3 months after SAH using the Glasgow Outcome Scale. Good outcome were observed in 40 cases among them 22 cases (42.3%) were able to return premorbid activities. Total mortality in this series were 10 cases (19.23%) which includes preoperative death while waiting for clipping -3 cases and postoperative death- 7 cases( 14.2%).Conclusion: There is no reason to postpone clipping surgery in patients who are eligible for surgery at day 5. Surgery after day 10 is associated with worse outcome. Although these studies is having high rate of mortality which can be progressively minimize by our continuous improvement of surgical skills and postoperative critical care management of aneurysm patients.Bangladesh Journal of Neuroscience 2012; Vol. 28 (1): 29-37

Aims Pre-operative radiotherapy has proven to reduce local recurrences after curative surgery for rectal cancer. Radiotherapy is generally well tolerated, although postoperative morbidity and mortality was increased in some patients. Current study was undertaken to analyse whether the interval between preoperative radiotherapy and surgery influences post-operative mortality and recurrence for two cohorts. Methods All Dutch patients included in the total mesorectal excision (TME)-trial receiving radiotherapy for resectable rectal cancer were included in this study ( n = 642). The verification set consisted of all patients receiving short-course radiotherapy for resectable rectal cancer in two radiotherapy clinics in The Netherlands ( n = 600). Univariate and multivariable survival analyses for overall survival, disease-free survival, local recurrence-free survival and non-cancer related survival were calculated. Results Patients aged 75 years and older treated during the TME-trial showed a worse overall and non-cancer-related survival when surgically treated 4–7 days after the last fraction of radiotherapy. No differences in survival between the interval groups were found in the verification set. Conclusion Present study found that elderly patients aged 75 years and older operated 4–7 days after the last fraction of radiotherapy had a higher chance of dying due to non-cancer-related causes during the TME-trial as compared to patients with an interval of 0–3 days. In the verification set similar differences could not be confirmed, which could be due to awareness of the clinicians who avoided delayed surgery after radiotherapy since the results have been presented during congresses. A longer than recommended interval between radiotherapy and surgery should be avoided. Besides, the verification set suggests that radiotherapy duration of 7 days is acceptable.

Background: This study was undertaken to investigate the growth rate and clinical outcome of patients with a small renal mass (SRM) after delayed surgery versus immediate surgery. Methods: We reviewed the clinical records of 328 patients with SRM ≦ 4cm at diagnosis, who underwent delayed or immediate surgical intervention from January 2000 to December 2011. Radiographic evaluation using CT scan and MRI were performed at least every 6 months and the tumor size was determined at least twice in the delayed surgery group. Results: A total of 292 RCC patients with pT1aN0M0 were identified; among them, 32 patients had been managed with delayed surgery intervention. No statistically significant difference was observed in overall survival rate (OSR) and cancer recurrence-free rate (CRFR). But cancer-specific survival rate (CSSR) was significantly lower in the delayed surgery group (p=0.0002). Conclusions: The overall survival rate of delayed surgery was not inferior compared with that after immediate surgery. Delayed surgery intervention for SRMs is a treatment option in the current study.

Contains fulltext : 118397pub.pdf (Publisher’s version ) (Closed access) BACKGROUND: To evaluate the efficacy and tolerability of preoperative short-course radiotherapy followed by capecitabine and oxaliplatin treatment in combination with bevacizumab and subsequent radical surgical treatment of all tumor sites in patients with stage IV rectal cancer. PATIENTS AND METHODS: Adults with primary metastasized rectal cancer were enrolled. They received radiotherapy (5 x 5 Gy) followed by bevacizumab (7.5 mg/kg, day 1) and oxaliplatin (130 mg/m(2), day 1) intravenously and capecitabine (1000 mg/m(2) twice daily orally, days 1-14) for up to six cycles. Surgery was carried out 6-8 weeks after the last bevacizumab dose. The percentage of radical surgical treatment, 2-year survival and recurrence rates, and treatment-related toxicity was evaluated. RESULTS: Of 50 included patients, 42 (84%) had liver metastases, 5 (10%) lung metastases, and 3 (6%) both liver and lung metastases. Radical surgical treatment was possible in 36 (72%) patients. The 2-year overall survival rate was 80% [95% confidence interval (CI) 66.3%-90.0%]. The 2-year recurrence rate was 64% (95% CI 49.8%-84.5%). Toxic effects were tolerable. No treatment-related deaths occurred. CONCLUSIONS: Radical surgical treatment of all tumor sites carried out after short-course radiotherapy, and bevacizumab-capecitabine-oxaliplatin combination therapy is a feasible and potentially curative approach in primary metastasized rectal cancer.

IntroductionThe objective of this investigation was to evaluate the effects of delayed surgery on infection rates of open tibia fractures in a rabbit model. Our hypothesis was that delaying irrigation and debridement (I&D) would increase the risk of bony and soft tissue infection when antibiotics were withheld.Materials and methodsA drill hole was created in the rabbit tibia and inoculated withStaphylococcus aureus. Animals underwent I&D at controlled delayed times of 6 hours (n = 11), 12 hours (n = 9) and 24 hours (n = 10). A stainless steel pin was inserted to mimic definitive fracture fixation with a metal prosthesis. No antibiotics were administered. Animals were sacrificed at 4 weeks and evaluated for infection.ResultsThe percent of soft tissue infections with I&D delays of 6, 12 and 24 hours were 18, 22 and 40%, respectively [p = 0.59; odds ratio (OR) = 3]. The percentage of animals with osteomyelitis with I&D delays of 6, 12 and 24 hours were 9, 22 and 50%, respectively (p = 0.12; OR = 10).DiscussionIn the current model, delaying I&D from 6 to 24 hours may increase the rate of postoperative osteomyelitis and further investigation is warranted.Kokko KP, Kang QK, Wen X, An YH, Barfield WR, Hartsock LA. Novel Rabbit Model for the Evaluation of Open Tibia Fractures: Effect of Delayed Surgery on Infection Rate. The Duke Orthop J 2013;3(1):48-53. I

Objective To determine if the time interval between excision procedure and definitive minimally invasive surgery (MIS) for cervical cancer impacts 30-day postoperative complications. Methods A retrospective cohort of patients diagnosed with cervical cancer from January 2000 to July 2015 was evaluated. Patients who underwent a cervical excision procedure followed by definitive MIS within 90days were included. Early definitive surgery was defined as ≤6 weeks following excision procedure, while delayed was defined as 6weeks to 3months. The primary outcome was 30-day complications. Statistical analysis included descriptive statistics and modified Poission regression. Results Overall, 138 patients met inclusion criteria. Of these, 33% ( n =46) had early definitive surgery and 67% ( n =92) had delayed definitive surgery. Median age was 42years (range 23–72years) and median BMI was 28kg/m 2 (range 16–50kg/m 2 ). Within demographic and surgical factors collected, only smoking status differed between groups with those in the delayed surgery group more likely to be non-smokers than those in the early surgery group ( p =0.04). When adjusting for relevant demographic and surgical factors, patients in the early group were twice as likely to have 30-day complication (aRR 2.6, 95%CI 1.14–5.76, p =0.02). Evaluating only women who underwent a radical procedure, 30-day complications remained higher in the early surgery group (RR 2.56; 95%CI 1.22–5.38, p =0.01). Conclusions Performing definitive MIS for cervical cancer within 6weeks after cervical excision is associated with increased risk for 30-day complications. Providers should consider delaying definitive surgical procedures for at least 6weeks following excision to reduce surgical com p lications.

The purpose of the present study is the comparison of acute ACL reconstruction with or without meniscus repair within 48 h after injury and a delayed surgery during the inflammation-free interval. It was hypothesized that acute ACL reconstruction results in inferior patient reported outcomes and higher frequency of range of motion deficits.The effect of acute (within 48 h) and delayed (during the inflammation-free interval) ACL surgery was prospectively studied on 160 consecutive patients with ACL injury between January 2010 and December 2011. Subgroup analyses were performed to evaluate patients with an additional meniscus repair separately from isolated ACL surgeries. During the study period, partial meniscectomies were recorded to evaluate time dependent meniscus reparability. Patient reported outcomes, objective IKDC and manual stability measurements were documented during the 24-month follow-up period. The Pearson Chi-squared test was used to evaluate objective outcome measures. The Mann-Whitney U test was performed to analyse the results of patient reported outcomes. Statistical significance was set at p 0.05.For patients who underwent isolated ACL reconstruction, no statistical significant difference was observed at any time point regarding objective and subjective outcome measures. Significantly fewer patients who underwent acute combined ACL reconstruction and meniscus repair had an extension deficit between 3° and 5° at 12 months following surgery (3.7 vs. 22.2 %, p 0.05). No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups. Further, surgical timing did not influence the reparability of the meniscus.An acute ACL reconstruction within 48 h is preferable in highly active patients or competitive athletes.Prospective cohort study, Level II.

// Mi Joo Chung 1 , Dong Wook Kim 1, * , Weon Kuu Chung 1 , Suk Hwan Lee 2 , Seung- Kyu Jeong 3 , Jae Kwan Hwang 4 and Choon Sik Jeong 5 1 Department of Radiation oncology, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea 2 Department of Surgery, Kyung Hee University School of Medicine, Seoul, Korea 3 Department of Surgery, Yang Hospital, Seoul, Korea 4 Department of Surgery, Yang Hospital, Namyangju, Korea 5 Department of Surgery, Hansol Hospital, Seoul, Korea * Co-first authors, these authors contributed equally to this work Correspondence to: Weon Kuu Chung, email: wkchung@khnmc.or.kr Keywords: chemoradiotherapy, preoperative treatment, rectal cancer Received: March 04, 2016 Accepted: June 07, 2016 Published: June 24, 2016 ABSTRACT Purpose: To compare the clinical outcomes between short-course chemoradiotherapy (CRT) and long-course CRT with delayed surgery in locally advanced rectal cancer patients. Results: From 2010 to 2015, 19 patients were treated with short-course CRT and 53 patients were treated with LCRT. The sphincter-saving rate (89.5% vs. 94.3%, short-course CRT vs. long-course CRT), pathologic complete remission (21.1% vs. 13.2%), downstaging (47.4% vs. 26.4%), and treatment complications including anastomotic site leakage, bowel adhesion, and hematologic toxicity associated with short-course CRT were not significantly different from those associated with long-course CRT. 2-year overall survival was 90.0% and 91.2% ( p = 0.448), respectively. Methods and materials: 72 patients with stage cT3-4N0-2M0 rectal cancer participated in a multicenter study. Short-course CRT treatment was as follows: a total of 25 Gy of radiotherapy was delivered in 5 equal doses with intensity modulated radiation therapy. Chemotherapy was consisted of Leucovorin 400 mg/m² administered by bolus injection on day 1 and 5-Fluouracil 1200 mg/m² given by continuous infusion on days 1 and 2. An additional three cycles of chemotherapy were administered before the surgery. Long-course CRT treatment was as follows: a total of 50.4 Gy of radiotherapy was delivered in 28 equal doses. Chemotherapy consisted of a bolus injection of 5-Fluouracil + Leucovorin during the first and last week of radiotherapy. Surgery was performed 6−8 weeks after completion of radiotherapy in both groups. Conclusions: Preoperative short-course CRT is an effective and safe modality. It is clinically comparable to long-course CRT in locally advanced rectal cancer.

WOS: 000408982500014, PubMed: 28275759, Stump appendicitis is an acute inflammation of remnant appendix, a rare complication of incomplete appendectomy. It may present as acute abdomen with history of appendectomy, which may cause delay in diagnosis. Therefore, incomplete appendectomy should be considered as a differential diagnosis of acute abdomen in patients with medical history of appendectomy. The present case is one of stump appendicitis 6 months after appendectomy. Stump appendectomy was performed and the patient was discharged 7 days after the operation without any complication.

Neoadjuvant chemoradiotherapy (nCRT) is used to downstage locally advanced rectal cancer before surgery. Accumulating data suggest that tumor response to nCRT is time dependent. A delay between nCRT and surgery may increase the proportion of patients that achieve a favorable response. However, delayed surgery beyond 6-8 weeks may increase the technical difficulty, and the risks of surgical complications and recurrence or metastasis. This article briefly reviews the relevant literature to evaluate the efficiency and safety of delayed surgery.Two non-cohort studies and 10 cohort studies were reviewed. The results were analyzed and the limitations discussed.Although debatable, the findings of the included studies are promising. Delayed surgery may increase the proportion of favorable tumor response without compromising prognosis. However, most of the studies were retrospective, which introduces bias into the evaluation.Delayed surgery is potentially useful, but this needs to be verified by further well-designed prospective trials.

Background: The optimal timing of surgery for infective endocarditis complicated by embolic stroke is unclear. We compared early versus delayed surgery in these patients. Materials and Methods: Between 1992 and 2007, 56 consecutive patients underwent open cardiac surgery for the treatment of infective endocarditis complicated by acute septic embolic stroke, 34 within 2 weeks (early group) and 22 more than 2 weeks (delayed group) after the onset of stroke. Results: The mean age at time of surgery was 45.7±14.8 years. Stroke was ischemic in 42 patients and hemorrhagic in 14. Patients in the early group were more likely to have highly mobile, large (＞1 cm in diameter) vegetation and less likely to have hemorrhagic infarction than those in the delayed group. There were two (3.7%) intraoperative deaths, both in the early group and attributed to neurologic aggravation. Among the 54 survivors, 4 (7.1%), that is, 2 in each group, showed neurologic aggravation. During a median follow-up of 61.7 months (range, 0.4∼170.4 months), there were 5 late deaths. Overall 5-year neurologic aggravation-free survival rates were 79.1±7.0% in the early group and 90.9±6.1% in the delayed group (p=0.113). Conclusion: Outcomes of early operation for infective endocarditis in stroke patients were similar to those of the conventional approach. Early surgical intervention may be preferable for patients at high risk of life-threatening septic embolism.

Hypertension is common among patients presenting for surgery, and is frequently untreated or inadequately treated. While the approach to the patient with hypertension presenting for anaesthesia is controversial, and the evidence base for appropriate clinical decisions is weak, this is a problem that practising clinical anaesthetists face on a regular basis. This article seeks to present a unified approach to the problem of a hypertensive patient presenting for surgery, and offers suggestions as to the appropriate management options. As far as possible, the recommendations contained in this article have been based on the best available evidence. The authors suggest that moderate degrees of hypertension (up to 180/120 mmHg), without obvious target organ disease, should never be grounds for postponing surgery. Even with greater degrees of hypertension, the relative risk of postponing surgery should always be considered. There is little evidence that, in patients without target organ disease, delaying surgery in order to establish antihypertensive therapy is beneficial. For very severe hypertension, the benefits of delaying surgery to establish adequate hypertensive control must be weighed against the risk of delayed surgery. Where a surgical delay is considered, adequate time to establish appropriate blood pressure control must be allowed, and there is no place for sudden “cosmetic” correction of blood pressure immediately prior to anaesthesia. Previously undiagnosed hypertension, presenting for the first time at surgery, requires a basic investigation of target organ disease prior to anaesthesia, and appropriate subsequent follow-up referral for further management.

Extracorporeal membrane oxygenation (ECMO) can be used as a bridge to decision for selected patients with mechanical complications related to myocardial infarction (MI). Here we report the case of a patient with a ventricular septal rupture (VSR) who was treated with ECMO as a bridge to stabilization before delayed surgery. Unfortunately, significant ascending aortic thrombosis with left main coronary involvement occurred despite appropriate heparin therapy.

Several clinico-imageological factors affect the neurological outcome following cervical cord injury. Studying these factors is essential for predicting the outcome. Thirty-three patients with acute cervical cord injury who were treated at our institute from 2000–2003, were assessed by the American Spinal Injury Association (ASIA) scoring and magnetic resonance imaging (MRI) of cervical spine. MR patterns of cord injury and length of damage were evaluated by senior neuroradiologist. They were followed up with ASIA score at the end of one year. Four factors were analyzed for their possible influence on outcome namely age, initial neurological status, timing of surgery, MR findings. Patients were divided into groups based on the factor studied, and the improvement was compared amongst the groups. Chi Square analysis was done to study the statistical association. All patients with ASIA Grade ‘D’ improved whereas none improved in ASIA grade ‘A’. Patients with cord edema showed good recovery (52%) compared to patients with cord contusion (0%). Among the patients with cord edema, improvement was better in three or less than three segments (84.6%) compared to more than three segments (16.66%). There was no significant difference in improvements between age groups> 40 years (45%) and > 40 years (46.1%) (p>0.05). The difference in improvements between early surgery (60%) and delayed surgery (33.33%) was also not significant (p>0.05). The single most important factor, which determines the outcome, is the initial neurological status following injury. The age of the patient and the timing of surgery do not seem to influence the outcome. MRI pattern of cord edema with less than three segments has best prognosis for recovery.

The timing of surgical stabilization of a thoracolumbar spine fracture in a polytrauma situation is controversial. While delayed surgery was considered safe and the norm, over the last few years there is an increasing amount of literature available that supports early stabilization of the spine fracture with good neurological and non-neurological outcomes. Adequate “resuscitation” of the patient prior to surgical intervention is of paramount importance to reduce surgery associated “second hit”. The “spine damage control” approach is a safe and appropriate management strategy in a polytrauma situation. Minimally invasive stabilization follows the principles of “damage control orthopedics” and appears to be a good surgical option.