Set Excision

[Laila Berri]

Endometrial excision is generally recommended for women who plan to have more children. For women who are beyond childbearing age, hysterectomy is generally recommended. As with any surgical procedure, there are risks associated with endometrial excision, including excessive blood loss, infection, scar tissue, and complications with future childbirth.

So, to summarize, the published data show a 19% chance of persistent or recurrent endometriosis after excision surgery by an expert, and a nearly 60% chance of a surgically proven cure, meaning that at a subsequent surgery no endometriosis was found. There is a big difference in the ability to remove all endometriosis between a surgeon who does 15-25 major endometriosis excision cases a month and those who dabble in it, so these results will not translate to all surgeries that are called excision. To be clear, there are many gynecologists who mean well and truly believe that excision of endometriosis is the best way to treat the disease, and they can often do a good job on superficial disease and endometriomas. The challenge is that deep disease is technically much more difficult to remove and requires significantly more skill by the surgeon, which is why it is very important who actually does your surgery. This is probably the main reason why there are so few expert excision surgeons, along with the fact that there is no national organization championing the need for it, or sponsoring fellowship training for excision.

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Excision should never be used to correct erroneous data and isunsuitable for that task as it does not restore any previous view ofthe facts. Consider using ordinary retraction to correct errorswithout removing history.

Legitimate motivations for removing data are veryrare. A common desire is to be able to erase mistakes,but this is almost always a questionable idea. If a past version of a databasecontained incorrect information, decisions may have been made based onthat incorrect information. It is usually much more valuable to beable to recover the basis for those decisions, even when that basis isknown to be incorrect than to pretend that mistakes never happened.(Imagine a source control system that removed the history of codedefects once they were fixed). In any case, excision is unsuitable forthe error-correcting task, as it does not restore any prior view ofthe facts.

There are, however, legitimate reasons to 'forget' data. Systems aresometimes interested only in data that happened within a certain timewindow, or keeping older data can be a source of liability. Or, youmay discover after recording data that you do not have the legal rightto store the data. Privacy laws might require you to excise data fromex-customers, etc.

More than one excision can occur between indexing jobs, and youshould avoid attempting to repeatedly excise/request-index in an attempt to makeexcision feels synchronous. It's not. If you need to coordinate with a databasethat is guaranteed to have your excision, you can accomplish this withsync-excise.

Schema datoms and datoms that are part of Datomic's bootstrap cannotbe excised. This includes all of the attributes of attributes, andthe excision attributes themselves. In addition, you cannot exciseanything in the db.part/db partition. Datoms about past excisions alsocannot be excised. Attempts to excise datoms that cannot be excisedwill be recorded, but have no effect.

When the target of excision is an entity, and a datom to be excised isa reference whose attribute has :db/isComponent true, then thecomponent entity (and all of its attributes) will be excised recursively.

To excise a specific entity, manufacture a new entity with a:db/excise attribute pointing to that entity's id. For example, ifuser 42 requests that his personal data be removed from the system,the transaction data would be:

To excise only specific attributes of an entity, create a transactionas in the previous step, but also specify a collection of:db.excise/attrs. For example, you might excise attributes thatcontain personally identifying information, such as usernames andemail addresses, while leaving untouched other attributes that mightbe valuable for aggregate queries.

To excise old values of a particular attribute, you can create anexcision for the attribute you want to eliminate, and then limit theexcision using either before or beforeT. Imagine trackingapplication events that have users, categories, and details. Eachattribute requires its own excise request. There are lots of events,and you don't need them after a certain time window, so you can getrid of all the pre-2012 events:

When excising an entire entity, all component entities are alsoexcised, as are all inbound references to the excised entity. Whenselecting particular attributes of an excised entity, both in- andoutbound values of that attribute involving the excised entity areexcised, and, if a component attribute, the component entity isexcised in its entirety.

Excision is lossy. Given a datom, you cannot ask "Was this datom inthe database before an excision?" If you could ask that question,then the datom is still present in some sense, which defeats thepurpose of excision.

However, you can query the predicates used for excision, which makesit possible to answer e.g. the more limited question "Has an excisionoccurred that might have affected this entity?" For example, to checkif entity 42 has had any data removed by excision, you can query with:

Note that the excise attributes themselves are protected fromexcision, so there is no way to 'erase your tracks'. Every excisioncreates a permanent record. This helps preserve a fundamental valueproposition of Datomic - it is a database that greatly facilitatesyour knowing why it is in the state it is in, and how it got there.Thus excision strikes a delicate balance between forgetting andremembering that you forgot.

At some point after the excision request, an indexing job willrun. The resulting index (and all future indexes) will no longercontain the datoms implied by the excision predicate(s). Furthermore,those same datoms will be removed from the transaction log.

Excision puts a substantial burden on background indexing. Largeexcisions can trigger indexing jobs whose execution time isproportional to the size of the entire database, leading to backpressure and reduced write availability. Try to avoid excising morethan a few thousand datoms at a time on a live system.

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Background: Over 60,000 women are treated for cervical intraepithelial neoplasia (CIN) each year in England, most by excision. Management of women who have incomplete excision is controversial and the subject of much debate. Consequently, the completeness of excision is often ignored in the planning of subsequent treatment. We aimed to assess the effect of completeness of excision on the risk of post-treatment disease.

Methods: We undertook a meta-analysis of studies published between Jan 1, 1960, and Jan 31, 2007, that studied the risk of post-treatment disease (ie, CIN of any grade or invasive cancer) in relation to completeness of excision. Studies were included if they described treatment of CIN by excision; numbers of women with involved margins; prevalence of and numbers of women with post-treatment disease in relation to margin status. Criteria for post-treatment disease had to be stated as a defined abnormal cytology or histology. Studies were excluded if they described treatment of cervical glandular intraepithelial disease (CGIN); if all or nearly all women had reflex hysterectomy done soon after initial treatment; if women were immunosuppressed (eg, if they were HIV-positive); or if no control group with disease-free margins was used. The endpoint of our analysis was the relative risk (RR) of post-treatment disease in those whose treatment histology suggested that excision was complete compared with those in whom excision was incomplete or uncertain. RR meta-analysis was done by use of a random effects model.

Interpretation: Incomplete excision of CIN exposes women to a substantial risk of high-grade post-treatment disease. Some of these women would be safer with a second treatment, especially if deep margins are involved, but most will need close follow-up for at least 10 years. Every effort should be made to avoid incomplete excision. Adding extensive ablation in the treatment crater to compensate for inadequate excision should be avoided because this might delay detection of inadequately treated invasive disease and because the effectiveness of additional ablation to destroy any residual CIN cannot be assessed. Furthermore, extensive ablation does not decrease any risk of preterm delivery in subsequent pregnancies.

DAO excision is a small surgical procedure that can permanently improve smile symmetry in many patients with facial paralysis. The procedure is usually performed in clinic and takes about 30minutes. Local anesthesia is provided to numb the area. Then, a small incision is made inside the mouth (this is a scarless surgery), and fibers of the DAO muscle are identified and removed. We then place a few dissolving stitches to close the incision. Patients can eat and drink normally after the numbing medication wears off (about an hour). Most patients only require Tylenol and Ibuprofen, if anything, for postoperative discomfort. Many patients will notice an immediate improvement in smile symmetry once the mild post-procedure swelling goes away (a few days after surgery).

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