Let us cut to the core: is core biopsy enough for subcentimeter breast cancer?

BACKGROUND: Breast conservation therapy has become a preferred method of treating early-stage breast cancer. As care continues to evolve, certain lesions allowed less invasive treatment options. A simplified explanation of early breast cancer care is detection, biopsy, surgery, and adjuvant therapy. The authors look to challenge that algorithm for a specific type of disease. METHODS: A retrospective review was performed to identify all subcentimeter breast cancer that underwent surgery after core biopsy. These cases (n = 115) were analyzed for biopsy technique and outcome of final surgical excision to find when no residual disease was found on final pathology, potentially rendering the surgical resection an unneeded procedure. RESULTS: The authors found that 17 of 115 patients (14.8%) who underwent biopsy for subcentimeter breast cancer had no residual disease found on final surgical resection. Although the subsets were small, the largest core needle resulted in negative pathology two of three times, while the smallest gauge, never resulted in negative resection at time of surgery. CONCLUSIONS: Nearly, fifteen percent of patients were found to have no residual disease on final surgical pathology. These results were obtained when the radiologist was simply trying to get tissue diagnosis. The authors postulate that this percentage could be even higher if protocols were initiated to biopsy these small lesions with larger core biopsies and possibly alleviate the need for formal surgery in these specific, small lesion.

Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair.

BACKGROUND AND OBJECTIVES: A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients. METHODS: A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups. RESULTS: Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence. CONCLUSION: Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

Does routine use of indocyanine green fluorescence angiography prevent anastomotic leaks? A retrospective cohort analysis.

BACKGROUND: Insufficient perfusion to anastomoses in colorectal surgery is known to lead to complications. This study aims to evaluate whether routine use of fluorescence angiography (FA) alters the incidence of anastomotic leaks after colorectal surgery. METHODS: This was a retrospective study of 554 colorectal resections with and without the use of intraoperative fluorescence angiography. Anastomotic leak rates and whether angiography altered surgical management were the main outcomes measured. RESULTS: The anastomotic leak rate was found to be 1.3% both with and without use of FA (p > 0.05). Significantly more alterations were made to planned anastomotic site in FA group (n = 13, 5.6%) as compared to the group prior to use of FA in whom no alterations were made (p < 0.05). CONCLUSIONS: No significant difference was found in anastomotic leak rates between the two groups studied. Routine use of fluorescence angiography significantly altered intra-operative decision-making without discernible change in clinical outcome.

Lighted ureteral stents in laparoscopic colorectal surgery; a five-year experience.

BACKGROUND: Ureteral injuries during colorectal surgery are a rare event, ranging in the literature from 0.28-7.6%. Debate surrounds the use of prophylactic lighted ureteral stents to help protect the ureter during laparoscopic surgery. It has been suggested that they help to identify injuries but do not prevent them. The authors look to challenge this. METHODS: Over 66 months, every laparoscopic or colectomy involving ureteral stents was recorded. Researchers documented any injury to the ureter intraoperatively. The chart was also reviewed for the complications of urinary tract infection (UTI) and urinary retention post-operatively. RESULTS: During the 66 months, 402 laparoscopic colon resections were done. There were no ureteral injuries. The lighted ureteral stent was identified during every case in the effort to prevent injury during dissection and resection. No catheter associated UTIs were identified, while 14 (3.5%) suffered from post-operative urinary retention. CONCLUSIONS: The authors of this study present a large series of colon resections with no intraoperative ureteral injuries. In addition, these catheters were not associated with any UTIs and a rate of urinary retention similar to that of the at large data. This series provides compelling data to use lighted ureteral stents during laparoscopic colon surgery.

Five Years, Two Surgeons, and over 500 Bariatric Procedures: What Have We Learned?

BACKGROUND: Bariatric surgery has become an increasingly popular method for weight loss and mitigation of co-morbidities in the obese population. Like any field, there is a desire to standardize and accelerate the postoperative period while maintaining safe outcomes. METHODS: All laparoscopic sleeve gastrectomies (LSG) and gastric bypasses (LGB) were performed over a 5-year period were logged along with several aspects of postoperative care. Trends were followed in aspects of postoperative care over years as well as any documentation of complications or re-admissions. RESULTS: A total of 545 LSGs and LBPs were performed between 2012 and 2016. Improvements were noted in nearly every field over time, including faster Foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (PCAs), and faster advancement of diet. There was also an abandonment of utilization of the ICU and step down setting for these patients, leading to significant decreases in hospital cost. There was no change in complications, re-operations, or re-admission in this time period. CONCLUSIONS: The surgeons involved in this project have built a busy bariatric surgery practice, while continually evolving the postoperative algorithm. Nearly every aspect of postoperative care has been deescalated while decreasing length of stay and cost to the hospital. All of this has been obtained without incurring any increase in complications, re-operations, or re-admissions. The authors of this paper hope to use this article as a launching point for a formal advanced recovery pathway for bariatric surgery at their institution and others.

Tubular Carcinoma of the Breast: A Single Institution's Experience of a Favorable Prognosis.

Tubular carcinoma is a subtype of invasive breast cancer that comprises 1 to 4 per cent of invasive breast cancers. Prior studies show nearly 100 per cent 15 year survival rate for tubular carcinoma compared to the 89.2 per cent five year survival of all breast cancers. These encouraging statistics beg the question should tubular cancers be treated as other invasive cancers, or can some patients be spared an invasive procedure or the side effects of adjuvant therapy? Fifty-seven cases of tubular carcinoma over 16 years were analyzed. All relevant aspects of the patient's history, treatment, and outcomes were documented. The aim was compare treatment outcomes of tubular breast cancer outcomes to that of all invasive breast cancers. Of the 57 patients, local recurrence was seen in two patients (3.5%) only one of which recurred as a tubular carcinoma (1.75%). There were no cancer-related mortalities. A look into our institution's data supported the notion that tubular carcinoma of the breast is a less aggressive histological type. Of our 57 cases, only two recurrences (3.5%) were noted and there were no cancer-related mortalities. Interestingly only one patient (1.75%) recurred as tubular carcinoma. Without controlling for adjuvant therapy, recommendations cannot be made for a less aggressive treatment plan at this point. Future randomized controlled trials may lead to a less aggressive treatment plan for this favorable subtype. On the basis of this study and others like it, physicians can give evidenced-based favorable prognosis with a diagnosis of tubular carcinoma of the breast.

Intraoperative indocyanine green fluorescence angiography--an objective evaluation of anastomotic perfusion in colorectal surgery.

The essentials for any bowel anastomosis are: adequate perfusion, tension free, accurate tissue apposition, and minimal local spillage. Traditionally, perfusion is measured by assessing palpable pulses in the mesentery, active bleeding at cut edges, and lack of tissue discoloration. However, subjective methods lack predictive accuracy for an anastomotic leak. We used intraoperative indocyanine green (ICG) fluorescence angiography to objectively assess colon perfusion before a bowel anastomosis. Seventy-seven laparoscopic colorectal operations, between June 2013 and June 2014, were retrospectively reviewed. The perfusion to the colon and ileum was clinically assessed, and then measured using the SPY Elite Imaging System. The absolute value provided an objective number on a 0-256 gray-scale to represent differences in ICG fluorescence intensity. The lowest absolute value was used in data analysis for each anastomosis (including small bowel) to represent the theoretical least perfused/weakest anastomotic area. The lowest absolute value recorded was 20 in a patient who underwent a laparoscopic right hemicolectomy for an adenoma, with no postoperative complications. Four low anterior resection patients had additional segments of descending colon resected. There was one mortality in a patient who underwent a laparoscopic right hemicolectomy. This study illustrates an initial experience with the SPY system in colorectal surgery. The SPY provides an objective, numerical value of bowel perfusion. However, evidence is scant as to the significance of these numbers. Large-scale randomized controlled trials are required to determine specific cutoff values correlated with surgical outcomes, specifically anastomotic leak rates.

A Month for Gallbladder Cancer: A Case Report of Four Gallbladder Cancers Over a 30-Day Period at a Community Hospital.

Gallbladder carcinoma is an exceedingly rare and fatal cancer. With stage 1 disease having a 5-year survival of only 50%, a diagnosis of gallbladder cancer carries a grim prognosis. Fortunately, especially in the developed world, it is exceedingly rare. Annual rates are reported as low as 1 - 2.5 per 100,000 people in the United States. Over the past 14 years, Newark Beth Israel in New Jersey has diagnosed 21 patients with gallbladder cancer. The purpose of this case report was to describe four new cases which occurred over a 30-day period in 2015 and review the risk factors, diagnosis and treatment strategies for this terrible disease.

High grade angiosarcoma fifteen years after breast conservation therapy with radiation therapy: A case report.

INTRODUCTION: Angiosarcoma is a rare tumor of the breast. Secondary angiosarcoma of the breast refers specifically to a tumor that arises after a latency period following radiation. With breast conservation therapy gaining significant popularity to that of mastectomy, more cases of secondary angiosarcoma continue to arise in the irradiated fields of these patients. PRESENTATION OF CASE: The authors describe the case of an 80 year old female who presented fifteen years after her surgery and radiation treatment with two bleeding skin lesions in her breast. These lesions were found to be high grade angiosarcoma upon excision. Due to high cardiac co-morbidity she was treated with re-excision and surveillance. DISCUSSION: This case is an example of a rare sequela to a common procedure. Breast conservation therapy with lumpectomy and radiation has become a popular technique in treating localized breast cancer. Radiation like all therapy has its known adverse effects. Further work is needed with the small amount of published cases of angiosarcoma after breast irradiation so that we may find optimal treatment plans for these patients. Like any rare entity, difficulty lies in accruing enough cases to compare prognosis and results. CONCLUSION: Secondary breast angiosarcoma diagnosis requires frequent follow ups and a high index of suspicion. With mastectomy giving the best chance of treatment in these cases, early detection is crucial in this rare sequela.