Male Breast Cancer: An Updated Review of Patient Characteristics, Genetics, and Outcome.

Male breast cancer (MBC) is a rare entity, underrepresented in population studies and clinical trials, resulting in management of MBC to be informed by current research on female breast cancer (FBC). A literature review was conducted by accessing relevant articles on 2 databases, by searching keywords "male breast cancer". A total of 29 articles from year 2011 to 2022 were selected for this review. The authors found that male breast cancer generally occurs later in life with higher stage, higher grade, and more estrogen receptor (ER) positive tumours. Most of the studies noted the mean age for MBCs at the time of presentation as >60 years. Risk factors for male breast cancer include family history, obesity, lower physical activity, and syndromes like the Klinefelter syndrome. Positive family history is much higher in MBC compared to FBC (30.9 vs. 18.4%). BRCA 2 cancers constitute a higher proportion compared to FBCs. A lot of genetic mutations have been observed. Some show promise to assess disease-specific survival and proliferative rate like TWIST1 and RUNX3, among others. MBCs usually present with a palpable lump in central region, with a bigger size and chance of nodal involvement and metastasis compared to FBCs. They are mostly infiltrating ductal type and hormone receptor positive, with worse histological grade. Treatment usually follows the same principles as FBCs (systemic therapy, surgical excision, and radiotherapy), with poorer prognosis to same treatment approach, possibly owing to its advanced stage at presentation. This is a rare entity which requires further research to ascertain need for different management approach than FBCs.

Pancreatic ductal adenocarcinoma: exploring clinicopathological trends and racial disparities in a comprehensive U.S. population-based study.

INTRODUCTION: Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy about 50% of PDAC are metastatic at presentation. In this study, we evaluated PDAC demographics, annual trend analysis, racial disparities, survival rate, and the role of different treatment modalities in localized and metastatic disease. METHODS: A total of 144,824 cases of PDAC were obtained from the SEER database from 2000 to 2018. RESULTS: The median age was 69 years, with a slightly higher incidence in males (52%) and 80% of all cases were white. Among cases with available data, 43% were grade III tumors and 57% were metastatic. The most common site of metastasis was the liver (15.7%). The annual incidence has increased steadily from 2000 to 2018. The overall observed (OS) 5-year survival rate was 4.4% (95% CI 4.3-4.6%), and 5 years cause-specific survival (CSS) was 5% (95% CI 5.1-5.4%). The 5-year survival with multimodal therapy (chemotherapy, surgery, and radiation) was 22% (95% CI 20.5-22.8%). 5-year CSS for the blacks was lower at 4.7% (95% CI 4.2-5.1%) compared to the whites at 5.3% (95% CI 5.1-5.4%). Multivariate analysis found male gender and black race associated with worse prognosis. Kaplan-Meier survival analysis found multimodal therapy to have the best outcomes in all three stages. CONCLUSION: PDAC is an aggressive malignancy with male gender and black race are associated with a poor prognosis. Surgery with chemoradiation was associated with the best overall survival. With steadily increasing rates of PDAC, improved treatment modalities are paramount to improving survival in these patients.

Calciphylaxis, A Case Series: The Importance of Early Detection.

Introduction: Calciphylaxis is a rare disorder that involves the formation of cutaneous, subcutaneous, and vascular calcifications. Although it is predominantly seen in patients with end-stage renal disease (ESRD), it has also been reported in patients without chronic kidney disease. The presence of multiple risk factors, a poorly understood mechanism, high mortality, and the lack of standardized treatment make calciphylaxis an important subject. Case Presentation: We describe the clinical presentation, disease course, and management of 3 patients with calciphylaxis and also provide a literature review. In all 3 patients, the diagnosis was confirmed histologically, and the management involved the continuation of renal replacement therapy, pain medication, wound debridement, and intravenous (IV) sodium thiosulphate. Conclusion: Calciphylaxis should be suspected in ESRD patients presenting with painful areas of cutaneous induration, and the early recognition of these findings allows for prompt diagnosis and management.

Parathyroid Carcinoma: Incidence, Survival Analysis, and Management: A Study from the SEER Database and Insights into Future Therapeutic Perspectives.

Introduction: Parathyroid carcinoma (PC) is an extremely rare entity, with a frequency of 0.005% of all malignancies. Most data related to this rare disease are limited to case series and a few database studies. We present a large database study that aims to investigate the demographic, clinical, and pathological factors, prognosis, and survival of PC. Methods: Data of parathyroid carcinoma were extracted from the Surveillance, Epidemiology, and End Results (SEER) diagnosed between 1975 and 2016. Results: PC had a slightly higher incidence in men (52.2%, p < 0.005), the majority of cases affected Caucasians (75.4%, p < 0.005), and the mean age at diagnosis was 62 years. Histologically, 99.7% were adenocarcinomas not otherwise specified (p < 0.005), well-differentiated (p < 0.005), and 2−4 cm (p < 0.001) in size among the patients with available data. In cases with staging provided, most PC were organ-confined (36.8%, p < 0.001). Lymph nodes were positive in 25.2% of cases where lymph node status was reported. The main treatment modality was surgery (97.2%), followed by radiation alone (2%), and very few received chemotherapy alone (0.8%), p < 0.005. Five-year follow-up was available for 82.7% of the cases. Those who underwent surgery only or radiation alone had 5-year survivals of 83.8% and 72.2%, respectively (p < 0.037). Multivariable analysis identified tumor size >4 cm, age > 40 years, male sex, Caucasian race, distant spread, and poorly differentiated grade as independent risk factors for mortality (p < 0.001). Conclusion: PC is a very rare tumor mostly affecting Caucasian individuals in the fifth decade. Older age, poor histologic differentiation, and distant metastasis are associated with a worse prognosis. Surgical resection offers the best survival outcome. To better understand the pathogenesis and factors affecting survival, all PC patients should be enrolled in national and international registries.

Incidence, Survival Analysis and Future Perspective of Primary Peritoneal Mesothelioma (PPM): A Population-Based Study from SEER Database.

BACKGROUND: Primary peritoneal mesothelioma (PPM) is a rare and aggressive tumor arising from the visceral and parietal peritoneum. The diagnosis and treatment of PPM are often delayed because of non-specific clinical presentation, and the prognosis is worse. The current study investigated the demographic, clinical, and pathological factors affecting patient prognosis and survival in PPM. METHODS: Demographic and clinical data of 1998 patients with PPM were extracted from the Surveillance Epidemiology and End Results (SEER) database (1975-2016). The chi-square test, paired t-test, and multivariate analysis were used to analyze the data. RESULTS: The majority of PPM patients were male (56.2%, p < 0.005) and Caucasian (90.4%, p < 0.005, with a mean age of diagnosis was 69 ± 13 years. The grading, histological, and tumor size information were classified as "Unknown" in most of the cases, but when available, poorly differentiated tumors (8.7%), malignant mesothelioma, not otherwise specified (63.4%) and tumors > 4 cm in size (8%), respectively, were most common, p < 0.005. Chemotherapy was administered to 50.6% of patients, followed by resection (29.2%) and radiation (1.5%), p < 0.001. The cohort of PPM had a five-year overall survival of 20.3% (±1.1), compared to 43.5% (±5.9), 25.9% (± 8.4), and 18.7% (±1.6) for those with surgery, radiation, or chemotherapy alone, respectively. Poor differentiation (OR = 4.2, CI = 3.3-4.9), tumor size > 4 cm (OR = 3.9, CI = 3.2-4.5), Caucasian race (OR = 2.9, CI = 2.6-4.4), and distant SEER stage (OR = 2.5, CI = 1.1-3.2) were all linked with increased mortality (p < 0.001). CONCLUSION: An extremely rare and aggressive peritoneal tumor, PPM may be difficult to identify at the time of diagnosis. Radiation therapy likely to have a limited function in the treatment of this condition, with surgery and chemotherapy being the primary choices. All PPM patients should be enrolled in a nationwide registry to improve our understanding of the pathogenesis and identify factors affecting survival.

Outcomes of patients with invasive mucinous and tubular carcinomas of the breast.

Invasive tubular carcinoma (ITC) and invasive mucinous carcinoma (IMC) of the breast are rare histologic subtypes of breast cancer associated with favorable prognoses. The aim of our study was to investigate the outcomes for these rare subtypes using the National Cancer Database. Female patients diagnosed with ITC or IMC between 2005 and 2014 were analyzed. The primary outcome was overall survival (OS), and we analyzed its association with adjuvant therapy. 2735 patients with ITC and 5602 patients with IMC were identified. ITC presented in younger patients (57 vs. 67 years), had smaller tumors (size <1 cm, 63.1% vs. 25.4%), earlier stage, and less node-positive disease (5% vs. 8.6%), compared with IMC. Older age, government insurance, lower income, treatment in a community cancer program, large tumor size, positive nodal status, and without endocrine therapy were associated with worse OS with either subtype on multivariate analysis. No OS benefit was found for node-positive ITC that received adjuvant chemotherapy compared with those who did not. (5-year OS of 96.0% vs. 91.3%, p = 0.17).OS was improved for IMC that received adjuvant chemotherapy (10-year OS: 82.5% vs. 60.1%, p = 0.008) and endocrine therapy (10-year OS: 86.6% vs. 81.2%, p < 0.001). We concluded that ITC has favorable clinicopathological characteristics and prognosis, even with node-positive disease. ITC and IMC may need to be evaluated independently when administering adjuvant treatment plans.

Improving Adenoma Detection Rates: The Role of the Fecal Immunochemical Test.

Background There is limited knowledge about adenoma detection rates (ADRs) in patients with a positive fecal immunochemical test (FIT). We hypothesized that colonoscopy performed after FIT would result in higher ADRs. Methods We reviewed ADRs for colonoscopies performed after a positive FIT test and compared them to ADR rates for routine colonoscopy performed without an initial FIT test between November 2014 and March 2017 at multiple endoscopy sites. Results A total of 979 patients underwent a FIT testing in the Texas panhandle, of whom 12.1% (n=119) tested positive. Also, 32.8% (n=39) were found to have one or more tubular adenomatous polyps on final pathological examination. Among these patients, the majority were female (64.1%; n=25). Of the patients, 15.9% (n=19) had a hyperplastic polyp, 1.7% (n=2) had findings consistent with ulcerative colitis, and 0.8% (n=1) were positive for an adenocarcinoma. In the control group of 2,603 patients in whom routine colonoscopy was performed as the initial tool for screening, 719 were found to have one or more tubular adenomas, with an ADR rate of 27.5%. In this group, the cancer rate was found to be 1%. Conclusions There was a significant increase in the ADR when colonoscopy is conducted after a positive FIT test. Recommending colonoscopies after a positive FIT test will not only improve ADRs significantly but also lower the overall healthcare cost for screening colon cancer in this era of escalating healthcare costs.

Clinicopathologic Characteristics and Prognosis of Invasive Papillary Carcinoma of the Breast.

BACKGROUND: Invasive papillary carcinoma (IPC) of the breast is thought to carry a more favorable prognosis than invasive ductal carcinoma (IDC). The aim of this study is to investigate the clinicopathological characteristics between IPC and IDC and their prognosis using a large nationwide data set. METHODS: Female patients diagnosed with malignant IPC and IDC between 2005 and 2014 were analyzed. Patients with incomplete survival data, stage 0/IV, unknown stage, or recurrent disease were excluded. Five-year overall survival was compared between IPC and IDC. RESULTS: Among 308,426 patients, 1147 had IPC and 307,279 had IDC. IPC presented more in older postmenopausal women, black Americans, and people who had government insurance. IPC had larger tumor size, lower-grade, and earlier-stage disease, less node-positive disease, higher hormone positivity, and lower human epidermal growth factor receptor 2 amplification. Adjuvant radiation and chemotherapy rates were lower in IPC than those in IDC. IPC had a similar 5-year overall survival as compared with IDC overall (86.8% versus 88.7%) (P = 0.06). Age, pathologic stage, and radiation treatment were shown to be independent prognostic factors of IPC. CONCLUSIONS: IPC has a similar prognosis as IDC, suggesting that these patients should follow the same treatment protocols.

A rare isolated cutaneous metastatic mass after colon cancer resection.

Metastatic cutaneous lesions from colorectal in origin are extremely rare, and especially without any visceral metastasis. Due to its poor response to chemotherapy, it is a poor prognostic indicator with a 1-6 month(s) death rate. Routine screening colonoscopy should be highly encouraged. This case is about a patient with obstructing, bleeding right colon mass and metastatic cutaneous soft tissue mass postcolonic mass resection. The biology and the mechanism of these metastatic lesions are not well understood, and they can be mistaken with any other primary soft tissue malignancy.

Diversity, Equity and Inclusion in Medicine: Why It Matters and How do We Achieve It?

Diversifying the medical work force is critical to reducing health care disparity and improving patient outcomes. This manuscript offers a comprehensive review of best practices to improve both the recruitment and the retention of underrepresented minorities in training programs and beyond.

Carcinosarcoma of the Uterus: A Study From the Surveillance Epidemiology and End Result (SEER) Database.

BACKGROUND: Uterine cancer (UC) is one of the leading gynecologic neoplastic disorders in the United States (US), of which over 80% are endometrioid adenocarcinomas (EA). In contrast to EA, carcinosarcoma (CS) of the uterus is a sporadic and highly malignant tumor, phylogenetically containing both epithelial and mesenchymal histologic elements. This study sought to analyze demographic, pathological retrospectively, and survival characteristics of a large cohort of CS patients compared to EA patients to identify prognostic factors and treatment approaches that may improve the current clinical management of CS patients. METHODS: Demographic and clinical data were abstracted from 88,530 patients diagnosed with uterine malignancy from the Surveillance, Epidemiology, and End Results (SEER) database for 38 years (1973-2010). Extracted variables were analyzed using the Chi-square test, paired t-test, and multivariate analysis, while Kaplan-Meier functions were used to compare survival between groups. Statistical analyses were performed with IBM Statistical Product and Service Solutions (SPSS©), version 20.2 (IBM Corp., Armonk, NY). RESULTS: A total of 3,706 cases of CS comprised 38.2% of uterine sarcomas (n=9,702), and 4.1% of uterine cancers overall (n=88,530). EA made up 88.6% (n=78,481) of all uterine cancers. CS patients presented later in life (68.3±11.5 years) than EA (61.9±12.5 years). 65.2% of CS and 77.8% of EA occurred in Caucasians. The incidence (per million) of EA was higher in Caucasians compared to African-Americans (AA) (41% vs. 26.8%), while the incidence of CS was higher among AA than Caucasians (4% vs. 1.9%, p<0.001). 33.4% of CS was poorly differentiated at presentation, compared to 13.1% of EA. 27.8% of CS patients presented with a distant disease compared to only 4.7% of EA patients. 29.9% of AA patients with CS presented with metastatic disease, compared to 28.2% of Caucasian patients (p<0.001). Mean survival for CS patients (6.6±0.2 years) was significantly lower than that of EA patients (17.7±0.7 years, p<0.001), and AA CS patients had significantly lower survival than Caucasians CS patients (4.5±0.4 years vs. 7.1±0.3 years, p<0.001). CS patients treated with combined surgery and radiotherapy had the highest survival (9.4±0.5 years, p<0.001), while EA patients treated with surgery alone had the highest survival (20.4±1.2 years, p<0.001). Survival among AA CS patients treated with combination therapy was significantly inferior compared to Caucasians (6.5±0.6 years vs. 9.8±0.5 years, p<0.001). Multivariate analysis identified CS histology (odds ratio [OR] 1.9, CI=1.7-2.1), AA race (OR 1.3, CI=1.2-1.4), age over 40 (OR 3.4, CI=2.9-4.1), undifferentiated grade (OR 3.0, CI=2.6-3.4), and distant metastases (OR 6.2, CI=5.8-6.8) as independently associated with increased mortality (p<0.005). The use of radiotherapy in CS patients was independently associated with decreased mortality (OR 0.1, CI=0.02-0.6, p<0.005). CONCLUSIONS: Uterine CS is a highly malignant tumor with a significantly worse prognosis than EA. AA has a considerably higher CS incidence compared to EA. Moreover, AA CS had higher tumor grades, higher rates of metastatic disease, and experienced significantly lower overall survival compared to Caucasians despite receiving similar therapy. Primary radiotherapy or combination radiotherapy confers a survival advantage to AA uterine CS patients.

Comparative Analysis of Acral Melanoma in Chinese and Caucasian Patients.

BACKGROUND: Acral melanoma (AM) is a rare subtype of melanoma, which is one of the least common in Caucasian patients but is a common subtype of melanoma in Chinese patients. It is unclear if prognosis differs between Chinese and Caucasian patients diagnosed with AM. The aim of our study is to investigate patient characteristics and survival differences between Chinese and Caucasian AM patients. METHODS: Two large institutional melanoma databases from Fudan University Shanghai Cancer Center (FUSCC) and Mayo Clinic enterprise were retrospectively reviewed from 2009 to 2015. Clinicopathologic and survival data were collected and analyzed between the two groups. The primary outcome was disease-specific survival (DSS) and was calculated using the Kaplan Meier (KM) method. RESULTS: The Chinese group presented with more advanced disease compared with Caucasians: thicker Breslow depth (median 3.0 mm vs. 1.2 mm, p=0.003), more ulcerated disease (66.1% vs. 29%; p < 0.001), and advanced stages (stage II/III 84.3% vs. 37.1%; p < 0.001). No significant difference was identified in terms of age at diagnosis, location, histologic subtypes, or node positive rate. The 5-year DSS rate was 68.4% and 73% (p=0.56) in Chinese and Caucasians AM patients, respectively. Male gender, Breslow thickness, ulceration, and positive sentinel lymph nodes were independent poor prognostic factors on multivariate analysis. CONCLUSIONS: There appears to be no difference in stage-stratified survival between Chinese and Caucasians, supporting the implementation of clinical trials for AM that could include both Chinese and Caucasian patients.

Ad astra per aspera (Through Hardships to the Stars): Lessons Learned from the First National Virtual APDS Meeting, 2020.

OBJECTIVE: After COVID-19 rendered in-person meetings for national societies impossible in the spring of 2020, the leadership of the Association of Program Directors in Surgery (APDS) innovated via a virtual format in order to hold its national meeting. DESIGN: APDS leadership pre-emptively considered factors that would be important to attendees including cost, value, time, professional commitments, education, sharing of relevant and current information, and networking. SETTING: The meeting was conducted using a variety of virtual formats including a web portal for entry, pre-ecorded poster and oral presentations on the APDS website, interactive panels via a web conferencing platform, and livestreaming. PARTICIPANTS: There were 298 registrants for the national meeting of the APDS, and 59 participants in the New Program Directors Workshop. The registrants and participants comprised medical students, residents, associate program directors, program directors, and others involved in surgical education nationally. RESULTS: There was no significant difference detected for high levels of participant satisfaction between 2019 and 2020 for the following items: overall program rating, topics and content meeting stated objectives, relevant content to educational needs, educational format conducive to learning, and agreement that the program will improve competence, performance, communication skills, patient outcomes, or processes of care/healthcare system performance. CONCLUSIONS: A virtual format for a national society meeting can provide education, engagement, and community, and the lessons learned by the APDS in the process can be used by other societies for utilization and further improvement.

Completion lymph node dissection in patients with sentinel lymph node positive cutaneous head and neck melanoma.

BACKGROUND: Relatively few cutaneous head and neck melanoma (CHNM) patients with were included in the multicenter selective lymphadenectomy trial II (MSLT-II). Our objective was to investigate whether immediate completion lymph node dissection completion of lymph node dissection (CLND) was associated with survival benefit for sentinel lymph node (SLN) positive CHNM using the National Cancer Database. METHODS: SLN positive patients with CHNM from 2012 to 2014 were retrospectively analyzed. Patients were divided into two groups: those who underwent SLN biopsy (SLNB) only versus those who underwent SLNB followed by CLND (SLNB + CLND). The primary outcome was 5-year overall survival (OS). RESULTS: Among 530 SLNB + patients, 342 patients underwent SLNB followed by CLND (SLNB + CLND). The SLNB only group had fewer positive SLN, less advanced pathologic stage, and a lower rate of adjuvant immunotherapy. There was no significant difference in 5-year OS between the two groups (51.0% vs 67%; P = .56). After adjusting for pathologic stage, there remained no difference in 5-year OS among patients with stage IIIA (63.0% vs. 73.6%, P = 0.22) or IIIB/IIIC disease (39.1% vs 57.8%; P = .52). Conclusions Using a large nationwide database, CLND was not shown to be associated with improved OS for patients with SLNB positive CHNM, validating the results of MSLT-II.

Thrombocytopenia with multiple splenic lesions - histiocytic sarcoma of the spleen without splenomegaly: A case report.

BACKGROUND: Histiocytic sarcoma (HS) of the spleen is reported to be a rare and lethal disease. The clinicopathological features of splenic HS have not been well described. The objective of this paper is to describe the diagnosis and treatment of a case of this rare disease and provide a review of the literature. CASE SUMMARY: In this article, we discuss the case of a 40-year-old Hispanic female who presented with progressive thrombocytopenia and multiple hypoechoic lesions in the spleen without splenomegaly. Positron emission tomography-computed tomography showed increased activity in cervical lymph nodes, as well as multiple bone and splenic lesions with positive uptake. Two bone marrow biopsies and fine-needle aspiration of the cervical lymph node were inconclusive. Laparoscopic splenectomy was performed, and gross examination showed a 110.1 g spleen with multiple rubbery, nodular lesions within the subcapsular sinus and splenic parenchyma. The microscopic findings showed multinodular histiocyte proliferation with atypia and multilobulated nuclei, which were positive for CD163, CD4, and CD68 by immunohistochemical analysis. The final pathologic diagnosis was difficult and was found to be low-grade HS of the spleen, after consultations with two renowned hematopathology institutions. At the patient's five-month follow-up visit, her bone marrow metastasis had progressed. She is waiting to be enrolled in a clinical trial. CONCLUSION: Pathologic diagnosis of splenic HS can be challenging. Low-grade differentiation may be associated with a slow progressive disease.

Acral Lentiginous Melanoma: Incidence and Survival in the United States, 2006-2015, an Analysis of the SEER Registry.

BACKGROUND: Acral lentiginous melanoma (ALM) is one of the four major subtypes in cutaneous malignant melanoma (CMM). We aimed to study the incidence and survival of ALM in the United States in recent 10 y and compare the survival between ALM and nonacral CMM. In the meantime, racial disparity and prognostic factors associated with survival were investigated. METHODS: All the cases of ALM registered in the Surveillance, Epidemiology, and End Results registry from 2006 to 2015 were retrieved, including non-Hispanic whites (NHW), black Americans (blacks), Asian/Pacific Islanders, and Hispanic whites. Age-adjusted incidence was calculated. Clinicopathologic data, including age, gender, race, geographic location, Breslow thickness, ulceration, pathologic staging, sentinel lymph node status, and surgical approach, were collected and analyzed. Melanoma-specific survival (MSS) was analyzed in patients with ALM and CMM. The Kaplan-Meier method was used to estimate the influence of clinicopathologic data on ALM MSS. Only cases with complete staging and active follow-up were included in prognostic factor analysis. RESULTS: A total of 1724 ALM and 87,442 nonacral CMM patients were included in the study. For ALM patients, the age-adjusted incidence rate was 2.0 per million person-years. The proportion of ALM among all melanoma subtypes was greatest in blacks (32.6%). The 5-y MSS rates of ALM were lower than CMM overall (80.6% versus 93.0%, P < 0.001, respectively). When controlled by stage, the difference was significant in patients diagnosed at stages I and III. ALM 5-y MSS rates were highest (84.3%) in NHW, intermediate in Asian/Pacific Islanders (76.6%), Hispanic white (72.0%), and lowest in blacks (66.9%). Blacks were elderly, male predominant, located in East and Middle American, and had thicker, more ulcerated, advanced disease as compared with NHWs. When controlled by stage, survival difference was significant between NHWs and blacks in stage I (P = 0.004) and stage III (P = 0.005) patients. Gender, race, sentinel lymph node status, and pathologic stage were identified as independent risk factors in multivariate analysis. CONCLUSIONS: The incidence of ALM has been steady in recent 10 y and more prevalent in aged people. ALM is associated with a worse prognosis than CMM. Black Americans have the worst prognosis, and survival difference is significant between NHW and blacks.

Assessing the Long-term Patency and Clinical Outcomes of Venous and Arterial Grafts Used in Coronary Artery Bypass Grafting: A Meta-analysis.

Introduction The long-term patency of the grafts used during the coronary artery bypass grafting (CABG) is one of the most significant predictors of the clinical outcomes. The gold standard graft used during CABG with the best long-term patency rate and the better clinical outcomes is left internal thoracic artery (LITA) grafted to the left coronary artery (LCA). The controversy lies in choosing the second-best conduit for the non-left coronary artery (NLCA) with similar patency rate as LITA. This meta-analysis examines the long-term patency and clinical outcomes of all arterial grafts versus all venous grafts used during the CABG. Methods A comprehensive literature search of all published randomized control trials (RCTs) assessing long-term patency and clinical outcomes of grafts used in CABG was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2018). Keywords searched included combinations of "CABG", "venous grafts in CABG", "arterial grafts in CABG", "radial artery grafts in CABG", "gastroepiploic artery grafts in CABG", "patency and clinical outcomes". Inclusion criteria included: RCTs comparing the long-term patency, and clinical outcomes of radial artery, right internal thoracic artery, gastroduodenal artery, and saphenous vein grafts used in CABG. Long-term patency of the grafts and clinical outcomes were analyzed. Results Eight RCTs involving 2,091 patients with 1,164 patients receiving arterial grafts and 927 patients receiving venous grafts were included. There was no difference between the long-term patency rate (relative risk (RR) = 1.050, 95% confidence interval (CI) = 0.949 to 1.162, and p = 0.344), overall mortality rate (RR = 1.095, 95% CI = 0.561 to 2.136, and p = 0.790), rate of myocardial infarction (MI) (RR = 0.860, 95% CI = 0.409 to 1.812, and P = 0.692), and re-intervention rate (RR = 0.0768, 95% CI = 0.419 to 1.406, and P = 0.392) between arterial and venous grafts. Conclusion The use of arterial conduits over the venous conduits has no significant superiority regarding the long-term graft patency, the rate of MI, overall mortality, and the rate of revascularization following CABG. Additional adequately powered studies are needed to further evaluate the long-term outcomes of arterial and venous grafts following the CABG.

Comparison of Intraoperative Outcomes between Single-incision Robotic Cholecystectomy and Multi-incision Robotic Cholecystectomy.

Background The aim of this study was to evaluate the differences in the key surgical factors for single-incision robotic cholecystectomy (SIRC) and multi-incision robotic cholecystectomy (MIRC). Methods A retrospective data review from August 2013 to April 2018 consisting of 104 SIRC and 105 MIRC cases was done considering factors including patient gender, age, operating time (skin incision to skin closure), robotic console time (docking to undocking), the preoperative diagnosis for surgery, any complications in surgery, length of stay (LOS), and estimated blood loss (EBL). Procedures with conversion away from original robotic cholecystectomy approach were excluded. Chi-square analysis (p-value: 0.05) was run between the two data sets. Results A total of 209 robotic cholecystectomy cases were reviewed since 2013. We found significantly less time with single-incision compared to multi-incision (single incision = 94.0 minutes, multi-incision = 99.9 minutes, p = 0.016) and EBL (single-incision = 11.52 mL, multi-incision = 17.17 mL, p = 0.004). There was no significant difference in age or robotic console time. The most common indication was symptomatic cholelithiasis overall, with equal cases of dyskinesia in single-incision approach, although there was no significant difference in indication between the two approaches. Intraoperatively, there was marginally significant use of irrigation in multi-incision (multi-incision 45 [42.9%], single-incision 31 [29.8%], p = 0.0499) and no difference in Firefly, perforation, or intraoperative cholangiogram use. LOS results showed significant decreased stay in SIRC cases (single-incision 84 outpatients [80.8%], multi-incision 75 [71.4%]; p = 0.0379). Conclusions SIRC and MIRC are both safe and feasible ways to remove the inflamed/dysfunctional gallbladder. SIRC is associated with less operative time, less blood loss, and shorter hospital stay.

Acute epiploic appendagitis at the tip of the appendix mimicking acute appendicitis: A rare case report with literature review.

BACKGROUND: Acute epiploic appendagitis of the appendix (AEAA) is a rare self-limiting inflammatory disorder of the epiploic appendages (EA) close to the vermiform appendix, which often times mimicking the presentation of acute appendicitis (AA). To date, very few cases of AEAA have been reported. We report a case of a 52-year old man with the clinical suspicion of AA, but post-operative specimen examination confirmed AEAA as the final diagnosis. CASE SUMMARY: A 52-year-old morbidly obese man presented to the emergency department with a 1-d history of the right lower quadrant (RLQ) abdominal pain. Physical examination revealed localized RLQ tenderness mimicking AA. The computed tomography abdomen was inconclusive, and a decision was made to perform laparoscopic appendectomy (LA). During the LA, an infarcted epiploic appendage at the tip of appendix and adherent to the abdominal wall was found, which was entirely excised. Final pathology showed congested and hemorrhagic epiploic appendage without any accompanied acute inflammatory changes in the wall of the appendix. Postoperative course was uneventful and he was doing well at seven months follow-up. CONCLUSION: The possibility of AEAA should be considered in patients clinically suspected of having AA. Surgery is considered for those refractory to conservative management, with inconclusive diagnosis or develop complications at presentation.

Clinical suspicion is key: an unusual presentation of septic arthritis after distal pancreatectomy.

Septic arthritis is the result of an infectious agent gaining access a sterile joint. This results in a devastating inflammatory response that leads to rapid destruction of intra-articular cartilage and with it significant morbidity. This case study reports an unusual presentation of septic arthritis following abdominal surgery; specifically, a distal pancreatectomy performed for an enlarged, mid-body pancreas mass involving the splenic artery. This is the first reported case of septic arthritis following abdominal surgery, though the exact etiology is unknown.