The Case for Early Antibiotic Commencement and Source Control in Paediatric Subdural Empyema: A Single-Centre Retrospective Case Series

<b><i>Background:</i></b> Subdural empyema is a neurosurgical emergency requiring prompt diagnosis and treatment. There is a debate between the benefits and risks of starting early antibiotics prior to surgical drainage as this is purported to reduce the rate of microbiological diagnosis. Here, we describe our experience of treating this potentially life-threatening condition, advocating for the early commencement of antibiotics and importance of source control in its treatment. <b><i>Methods:</i></b> Retrospective review of a prospectively collected electronic departmental database included all patients who were admitted to our unit with a diagnosis of subdural empyema over an 11-year period (2008–2018). Basic demographic data were collected. Further data pertaining to mode of presentation, surgical approach, causative organism, post-operative antibiotic regime, anti-seizure medications, length of hospital stay, further surgery, and neurological outcomes were extracted. <b><i>Results:</i></b> Thirty-six children underwent 44 operations for subdural empyema at our institution during the study period. Median age was 11.0 (range 0.2–15.8); 47.2% (17/36) were female. Over time, there was decreasing use of burr holes and increasing use of craniectomy as the index surgery. Using a combination of extended culture and polymerase chain reaction, a microbiological diagnosis was achieved in all 36 cases; the commonest causative microorganism was of the <i>Streptococcus anginosus</i> group of bacteria. Seven patients underwent repeat surgery, and 4 patients underwent a concurrent ENT procedure. No risk factors were significant in predicting the likelihood of re-operation (location of subdural empyema, age, index surgery type, inflammatory markers, concurrent ENT procedure, and microorganism) although it was notable that none of the patients undergoing a concurrent ENT procedure underwent repeat surgery (<i>p</i> = 0.29). Median length of stay was 12 days (range 3–74), and there were no inpatient or procedure-related mortalities. Clinical outcomes were good with 94.4% (34/36) categorized as modified Rankin Scale 0–3 at discharge and there were 2 cranioplasty-related complications. <b><i>Conclusions:</i></b> We observed an evolution of practice from limited surgical approaches towards more extensive index surgery over the study period. Given that a microorganism was isolated in all cases using a comprehensive approach, initiation of antibiotic therapy should not be delayed on presentation. Concurrent ENT surgery may be an important factor in providing aggressive source control thereby reducing the need for repeat surgery.

Long Term Outcomes of Surgical Excision of Giant Papillae with Mitomycin C and Amniotic Membrane Transplantation in the Treatment of Refractory Palpebral Vernal Keratoconjunctivitis

Background and Objectives: To report the long-term outcomes of patients with refractory Vernal Keratoconjunctivitis (VKC) who underwent surgical excision of giant papillae (GP) with mitomycin C (MMC) 0.02% and amniotic membrane transplantation (AMT). Materials and Methods: This is a retrospective interventional single-center case series including five eyes of four patients who had refractory, symptomatic VKC with GP, along with corneal shield ulcers and/or punctate epithelial erosions. They underwent surgical excision of GP with MMC 0.02% alone (1 eye) or with MMC 0.02% and AMT (4 eyes). Their long-term visual and surgical outcomes were studied. Results: All subjects were male with bilateral involvement and mean age of presentation 9.8 years. The surgery was uneventful in all cases. Amongst the four eyes which underwent MMC with AMT, only one eye demonstrated papillary regrowth requiring repeat surgery. Postoperative follow-up ranged from 59 to 77 months (median 66 months). Four patients had the best corrected visual acuity (BCVA) >/= 6/9.5. One patient had BCVA 6/15 at the final follow-up due to the presence of anterior corneal stromal scar and poor ocular surface. Conclusions: Surgical excision of GP in combination with MMC and AMT, in refractory VKC, is a good treatment option with better clinical outcomes over a longer follow-up.

Reoperation rates for recurrence of fibroids after abdominal myomectomy in women with large uterus

Background The population of women undergoing abdominal myomectomy for symptomatic large fibroid uterus is unique. We seek to characterize the timing, risk factors as well as the presenting symptoms which led patients to undergo repeat surgery in this patient population. Methods and findings We followed 592 patients who underwent an abdominal myomectomy from March 1998 to June 2010 at St. Vincent’s Catholic Medical Center and presented later during the study period with a recurrence of symptoms attributable to a reemergence of fibroids and who chose to undergo repeat surgical management. Twelve percent of patients exhibited symptoms of fibroid uterus which led to reoperation within the study period. The mean age at repeat surgery was 44.1 ± 0.6 years old (n = 69) and the mean time between operations was 7.9 ± 0.3 years. Presentation was variable but included bleeding, pain and infertility. Patients presented for surgery with a significantly smaller sized uterus than at their initial surgery. Timing between surgeries correlated with age at initial surgery and uterine size but race, number of fibroids, aggregate weight of fibroids removed, operative time or blood loss at the initial surgery did not correlate. Data is suggestive that intraperitoneal triamcinolone may reduce reoperation rates but not timing of recurrence. Conclusion These results may help in counseling patients, particularly younger women, on the risks of fibroid recurrence necessitating repeat surgery. Further research is necessary to assess if triamcinolone can alter fibroid reurrence in patients who undergo uterus sparing procedures.

Total Placenta Previa with High-risk MAP and Transverse Lie Fetal Position

Placenta accreta is one of the emergency conditions and has resulted in increased mortality and morbidity of pregnant women due to the massive obstetric hemorrhage. Placenta accreta can lead to secondary complications including coagulopathy, multisystem organ failure, acute respiratory distress syndrome, need for repeat surgery, and death. Assessment by anesthesia should be carried out as early as possible before surgery to reduce or even eliminate morbidity and mortality. In this report, we present the case of a patient with total placenta previa and high-risk MAP score with a transverse lie fetal position. The various anesthetic treatments and transfusion strategies are discussed with a multidisciplinary approach to delivery.

Laser treatment of macular retinal folds in late postoperative period after retinal detachment repair

Macular retinal folds are a rare yet grave complication of surgical rhegmatogenous retinal detachment repair. Clinical symptoms vary depending on the location and severity of folding. Fold located in the periphery of the ocular fundus can be asymptomatic, but macular retinal folds cause diminished visual acuity and metamorphopsia. Currently, the most effective treatment for retinal folds is repeat surgery. Its serious disadvantage is the risk of complications in the early postoperative period, including hemophthalmia, inflammation, secondary glaucoma, cataracts, RRD recurrence, macular tears, retinal vascular occlusion, etc. The clinical case described below demonstrates the potential of combination laser therapy for the treatment of macular retinal folds based on the use of modern diagnostic and therapeutic methods.

1306. Early Transition to Oral Antibiotics, Including Fluoroquinolone Therapy, for Streptococcus milleri Empyema Following Video-Assisted Thoracoscopic Surgery

Background Pleural empyema from Streptococcus milleri (SM) is often complex and requires a combination of surgery and intravenous (IV) antibiotics. There is a paucity of data on the efficacy of oral (PO) treatment due to concerns about the development of resistance, particularly to fluoroquinolones (FQ). We report outcomes of postoperative antibiotic treatment for SM empyema over 3 years, including PO therapy. Methods A single-center retrospective chart review was performed of 20 patients treated with video-assisted thoracoscopic surgery (VATS) from October 2015 to March 2018 and SM diagnosed by thoracentesis or operative culture. We reviewed clinical factors, route and duration of antibiotics, complications (empyema recurrence, repeat surgery, 30-day readmission due to empyema), and mortality (30-day and 1-year) Results Of the 20 patients, 12 (60%) received all IV and 8 (40%) transitioned to PO therapy (Table 1). Median age was 60 and 58 in the IV and PO group, respectively. IV treated patients had more comorbidities. Cultures were primarily monomicrobial. Isolates tested were susceptible (S) to penicillin (Table 1), Of 10 tested specimen, all had moxifloxacin MIC &lt; 0.19 μg/mL and 8/8 specimens tested were S to levofloxacin. The average duration of antibiotic therapy in the IV group was 34 days and 32 days in the PO group. There were no complications in the IV group: however, there were 2 deaths (1 patient died from comorbid complications and 1 patient was readmitted and died due to MSSA endocarditis). There were no complications or deaths in patients treated PO. Conclusion Our review suggests that early transition to PO antibiotics may be a viable option for operatively managed empyema caused by SM in certain patients. FQs have been generally avoided due to concerns about the rapid development of resistance that has been shown in-vitro; however, no in-vivo data have been reported regarding this concern. We show excellent outcomes with the use of PO therapy in susceptible isolates, particularly FQs, with no failure or reported resistance in patients with SM empyema treated with VATS. Further study is needed to validate these findings and determine optimal patient characteristics for transition to PO therapy. Disclosures All Authors: No reported disclosures

P.151 Repeat surgery for recurrent trigeminal neuralgia: a systematic review and meta-analysis

Background: The success of repeat surgery for recurrent trigeminal neuralgia (TN)—with microvascular decompression (MVD), percutaneous rhizotomy (PR), or stereotactic radiosurgery (SRS)—is not well-studied. We performed a systematic review and meta-analysis of the literature on repeat surgery recurrent TN, focusing on the durability of pain relief and relative efficacy of MVD, PR, and SRS. Methods: A PRISMA systematic review of Medline/Embase/Pubmed identified studies of adults with unilateral idiopathic TN undergoing repeat surgery. The primary outcome of complete pain relief (CPR) at last follow-up was analyzed with a multivariate mixed-effects meta-analysis of proportions. Results: Seventy-eight studies met criteria; 61 were included in meta-analyses, containing 29/14/25 cohorts with 900/684/1353 patients undergoing MVD/PR/SRS respectively (mean age 64.7 years, 41% males). Initial CPR was 69% (74%/85%/52%). CPR at mean 39.7 month follow-up (38.3/38.8/41.0) was 48% (59%/60%/34%). Initial CPR for both MVD (CPR: 0.78 [0.70-0.85]) and PR (CPR: 0.93 [0.83-0.98]) was superior to SRS (CPR: 0.48 [0.35-0.61]). At follow-up, MVD (0.45 [0.32-0.58]) and PR (0.45 [0.30-0.60]) trended towards superior CPR versus SRS (0.25 [0.15-0.37]). Conclusions: Half of recurrent TN patients achieve good pain control 3 years after repeat surgery. MVD/PR showed superior initial pain relief and likely better long-term relief. These findings can inform surgical decision-making in this challenging population.

P.161 Management of recurrent glioblastoma multiforme: An inter-observer variability study

Background: A significant proportion of glioblastoma multiforme (GBM) patients are considered for repeat resection, but evidence regarding best management remains elusive. Methods: An electronic portfolio of MR images of 37 cases of pathologically confirmed recurrent GBM with an accompanying clinical vignette was constructed. Surgical responders from various countries, training backgrounds, and years’ experience were asked for each case to select: their chosen management (repeat surgery, chemotherapy, radiation, or conservative), confidence in recommended management, and whether they would include the patient in a randomized trial that gave a 50% chance of re-operation. Responses were evaluated with kappa statistics and values interpreted according to Landis and Koch (0–0.2, slight; 0.21–0.4, fair; 0.41–0.6, moderate; 0.61–0.8, substantial; 0.81-1.0 perfect agreement). Results: 26 surgeons responded to the survey. Agreement regarding best management of recurrent GBM was slight, even when management options were dichotomized (repeat surgery vs. all others) (k=0.198 (95%CI 0.133-0.276). Country of practice, years’ experience, and training background did not improve agreement. Responders were willing to include more than 70% of patients in a randomized trial. Conclusions: Only slight agreement exists regarding the question of re-operation for patients with recurrent GBM. This supports the need for a randomized controlled trial.

P.165 Surgery for recurrent GBM: deciding when to operate

Background: Previous studies have found conflicting results regarding the role of repeat surgery on overall survival (OS) in patients with GBM. We used a novel approach that includes time to tumour recurrence as an additional prognostic factor in order to determine which patients benefit most from repeat surgery. Methods: A retrospective chart review from 1992-2018 was performed on all adult (≥ 18 years old) patients with primary GBM that received surgery for recurrent disease and compared to publicly available data from The Cancer Genome Atlas (TCGA) of adult patients with primary GBM that did not undergo surgery for recurrent disease. Results: A total of 672 adult patients with GBM were included in the study, including 87 that received surgery at tumour recurrence (surgery cohort). The surgery cohort had longer OS and similar complication rates to those that did not receive surgery at recurrence, independent of time to tumour recurrence (p < 0.0001 and p = 0.4, respectively). Within the surgery cohort, patients with tumour recurrence >6 months demonstrated additional survival benefit (p < 0.0001). Conclusions: Surgery for recurrent GBM leads to improved survival without increased complications. Patients with tumour recurrence >6 months benefit most from repeat surgery.