Introduction. Amputation for subungual malignancy (SUM) was thought to be the gold standard in preventing recurrence and metastasis. The rationale behind this aggressive treatment was never based on ...scientific evidence. Even though multiple recent studies supported more conservative management by illustrating successful results of the digit salvage technique, especially for “in situ” SUM, this salvage approach is not well supported for the more aggressive type of the “invasive” SUM; herein, we salvaged two cases of “invasive” SUM. Case Presentation. We present two cases of invasive SUM without radiographic evidence of intraosseous involvement, where we avoided digit amputation for both invasive subungual squamous cell carcinoma of the thumb and invasive subungual melanoma of the ring finger. Both were salvaged by using a triple technique under awake local anesthesia which included (I) radical excision of the nail bed unit including both eponychium and periosteum, (II) dorsal cortical bone shaving using a high-speed burr for the distal phalanx, and (III) flap coverage. Brunelli flap was used for the thumb in the first case, and V-Y plasty combined with proximal nail fold advancement flap was used for the ring finger in the second case. There was no evidence of local or distant recurrence, with a good functional outcome after 2.5 years in the first case and 2 years in the second. Conclusion. Ensuring complete resection with negative margins while preserving the functionality of the affected digit is considered to be the optimal challenge in treating “invasive” subungual malignancies. These two case reports contribute by reporting a successful digit salvage. The safety of this procedure could be confirmed by larger series and longer follow-up periods.
BackgroundMost studies investigating the relationship between preoperative frailty and postoperative outcomes among bladder cancer patients only assess frailty retrospectively in patients who have ...undergone radical cystectomy. Transurethral resection of bladder tumor (TURBT) is a commonly performed procedure in outpatient settings for a large number of bladder cancer patients. The prevalence of frailty among bladder cancer patients and its impact on postoperative complications and mortality are not well studied. MethodsTo assess the prevalence of frailty among bladder cancer patients planned for TURBT at a tertiary cancer center using the modified frailty index (mFI) and Risk Analysis Index (RAI) and further assess the impact of these indices on 30-day postoperative complications and mortality rates. ResultsBetween May 2020 and March 2021, 343 consecutive patients were enrolled. The mean age of the cohort was 64.8 ± 13.1 years, 86.6% were male, and 82% had non–muscle-invasive bladder cancer (NMIBC). The majority of the cohort (92%) was found to have low American Society of Anesthesiologists (ASA) score class (I + II), while 35.3% were labeled as frail using mFI 2+, and 32.1% based on RAI (III, IV). The 30-day readmission, postoperative complications, and mortality rates in this cohort were 3.8%, 2.3%, and 6.6%, respectively. RAI was a better indicator of mortality compared to mFI. As such, patients with low RAI score (I, II) had 0.054 odds for 30-day mortality compared to the patients with high RAI score (III, IV) (OR 0.054; CI 95%, 0.004 to 0.784; P = 0.033).Conclusion Frailty, as measured by Risk Analysis Index, is an independent predictor of early mortality in patients undergoing TURBT. Preoperative frailty assessment may improve risk stratification and patient counseling prior to surgery.
•Forequarter amputation is still used in orthopedic oncology as a treatment of last resort.•“Whoops” fixation refers to fracture fixation without investigating possible underlying ...conditions.•Oncological scenario must be ruled out in fractures preceded by trivial trauma.•Publishing such cases can participate in increasing the awareness of such cases and how to properly manage them.
Even with the advancement of limb salvage surgery techniques, forequarter amputation (FQA) is still used in orthopedic oncology. Even though it might pose catastrophic sequelae on the patient’s lifestyle, debilitating one’s ability to perform regular tasks, FQA is still considered as a treatment of last resort for huge fungating tumors of the upper extremity.
We present a case of an 18-year-old male patient, who was diagnosed in Libya with left proximal humerus fracture after a trivial trauma and underwent open reduction and internal fixation using k-wires as it was thought to be a simple fracture. Soon after, pain and swelling progressed severely and an open biopsy confirmed a diagnosis of osteosarcoma and imaging suggested metastatic disease to the lungs for which he was started on chemoradiotherapy. He was referred to our cancer center to continue his management and due to the aggressive nature of the tumor, the patient underwent palliative forequarter amputation followed by multiple lines of chemotherapy and radiotherapy, all of which failed to halt the progression of the disease. The patient was lost to follow up due to his decision to go back to Libya.
“Whoops” surgeries are fixated upon repairing fractures without looking for the alarming signs on radiographs to exclude pathological entity. As in our case, the procedure done escalated the osteosarcoma into such a massive fungating tumor due to the violation of the osteosarcoma pseudo capsule, in which the only available option is to do a palliative forequarter amputation.
The antenatal diagnosis of a combined esophageal atresia without tracheoesophageal fistula and duodenal atresia with or without gastric perforation is a rare occurrence. These diagnoses are difficult ...and can be suspected on ultrasound by nonspecific findings including a small stomach and polyhydramnios. Fetal magnetic resonance imaging adds significant anatomical detail and can aid in the diagnosis of these complicated cases. Upon an extensive literature review, there are no reports documenting these combined findings in a twin pregnancy. Therefore we believe this is the first case report of an antenatal diagnosis of combined pure esophageal and duodenal atresia in a twin gestation.
We present a case of a 30-year-old G1P0 white woman at 22-week gestation with a monochorionic-diamniotic twin pregnancy discordant for esophageal atresia, duodenal atresia with gastric perforation, hypoplastic left heart structures, and significant early gestation maternal polyhydramnios. In this case, fetal magnetic resonance imaging was able to depict additional findings including area of gastric wall rupture, hiatal hernia, dilation of the distal esophagus, and area of duodenal obstruction and thus facilitated the proper diagnosis. After extensive counseling at our multidisciplinary team meeting, the parents elected to proceed with radiofrequency ablation of the anomalous twin to maximize the survival of the normal co-twin. The procedure was performed successfully with complete cessation of flow in the umbilical artery and complete cardiac standstill in the anomalous twin with no detrimental effects on the healthy co-twin.
Prenatal diagnosis of complex anomalies in twin pregnancies constitutes a multitude of ethical, religious, and cultural factors that come into play in the management of these cases. Fetal magnetic resonance imaging provides detailed valuable information that can assist in management options including possible prenatal intervention. The combination of a cystic structure with peristalsis-like movement above the diaphragm (for example, "the upper thoracic pouch sign"), polyhydramnios, and progressive distention of the stomach and duodenum should increase suspicion for a combined pure esophageal and duodenal atresia.
The objective of this study was to compare generative artificial intelligence–initiated care pathways, using ChatGPT, with expert-guided consensus-initiated care pathways from AskMayoExpert (AME) for ...symptom management of esophageal cancer patients after esophagectomy.
A formal protocol for development of 9 AME care pathways was followed for specific patient-identified domains after esophagectomy for esophageal cancer. Domain scores were measured and assessed through the Upper Digestive Disease tool. These care pathways were developed by experts validated by a consensus-driven methodology. ChatGPT was used to answer specific questions similar to the AME care pathway on April 9, 2023, and March 28, 2024. To compare outcomes, answers were recorded, and algorithms were compared with a survey tool composed of 5 questions.
Both modalities were able to provide a clear definition with multidirectional management options for all 9 domains: dysphagia, generalized dumping, gastrointestinal dumping, pain, regurgitation, heartburn, nausea, physical health, and mental health. When provided with a simple prompt, ChatGPT 3.5 failed to provide a comprehensive stepwise approach for providers, any testing recommendations, or any form of triage process. However, ChatGPT 4.0 provided plans, similar to AME care pathways, when a sophisticated prompt was used.
Generative artificial intelligence–initiated care pathways can be used by physicians as a supplementary tool to guide provider management of patients with complex symptoms after esophagectomy. This technology will continue to advance but is currently insufficient to solely guide clinical management of complex patients with severe symptoms.
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One anastomosis gastric bypass (OAGB) is growing in popularity, although it is potentially associated with biliary gastritis and gastroesophageal reflux esophagitis, with a potential rise in ...esophageal carcinoma. We describe the surgical management of a 53-year-old man with history of OAGB in whom biliary reflux and esophageal adenocarcinoma developed. We performed a minimally invasive Ivor Lewis esophagectomy, resected the sleeved stomach pouch, created a new conduit out of the remnant greater curve of the remnant stomach with blood supply from an intact gastroepiploic artery, and created an esophagogastric anastomosis. This report may guide surgical management in the event that OAGB patients develop esophageal cancer.
This prospective study was conducted to determine postesophagectomy symptom severity of esophageal cancer survivors with use of the Upper Digestive Disease (UDD) questionnaire.
A prospective trial ...included adult esophagectomy patients diagnosed with primary esophageal carcinoma at a single institution from 2000 to 2011. Those who remained alive in 2015 to 2021 were enrolled. Comparison was made between sequential questionnaires.
From a prospective registry of 895 patients with esophagectomy for esophageal cancer, 297 (33%) long-term survivors were identified. Of those, 93 (31%) had recent contact data and 66 (71%) consented and completed the UDD questionnaire. Most participants, 77% (51), were men with a mean age of 57 (±7) years. The mean time from esophagectomy was 12 (8-20) years. The 66 enrolled patients completed 127 UDD questionnaires. A total of 27 (41%) completed at least 2 questionnaires. Poor performance was recorded in the 5 domains as follows: reflux, 19 patients (29%); pain, 3 patients (5%); dysphagia, 0 patients; gastrointestinal dumping, 31 patients (47%); and generalized dumping, 17 patients (26%). Between the first and second questionnaires, dysphagia had the most noticeable improvement in domain score (23/27 85%), and reflux had the most regression in domain score (7/27 26%).
Patient-reported outcome data are an integral part of esophageal cancer survivorship care. Having a standardized tool that would enhance research and standardize care pathway symptom management is needed.
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INTRODUCTIONAmputation for subungual malignancy (SUM) was thought to be the gold standard in preventing recurrence and metastasis. The rationale behind this aggressive treatment was never based on ...scientific evidence. Even though multiple recent studies supported more conservative management by illustrating successful results of the digit salvage technique, especially for "in situ" SUM, this salvage approach is not well supported for the more aggressive type of the "invasive" SUM; herein, we salvaged two cases of "invasive" SUM. Case Presentation. We present two cases of invasive SUM without radiographic evidence of intraosseous involvement, where we avoided digit amputation for both invasive subungual squamous cell carcinoma of the thumb and invasive subungual melanoma of the ring finger. Both were salvaged by using a triple technique under awake local anesthesia which included (I) radical excision of the nail bed unit including both eponychium and periosteum, (II) dorsal cortical bone shaving using a high-speed burr for the distal phalanx, and (III) flap coverage. Brunelli flap was used for the thumb in the first case, and V-Y plasty combined with proximal nail fold advancement flap was used for the ring finger in the second case. There was no evidence of local or distant recurrence, with a good functional outcome after 2.5 years in the first case and 2 years in the second. CONCLUSIONEnsuring complete resection with negative margins while preserving the functionality of the affected digit is considered to be the optimal challenge in treating "invasive" subungual malignancies. These two case reports contribute by reporting a successful digit salvage. The safety of this procedure could be confirmed by larger series and longer follow-up periods.
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