Objective breast symmetry analysis with the breast analyzing tool (BAT): improved tool for clinical trials.

PURPOSE: Objective cosmetic analysis is important to evaluate the cosmetic outcome after breast surgery or breast radiotherapy. For this purpose, we aimed to improve our recently developed objective scoring software, the Breast Analyzing Tool (BAT®). METHODS: A questionnaire about important factors for breast symmetry was handed out to ten experts (surgeons) and eight non-experts (students). Using these factors, the first-generation BAT® software formula has been modified and the breast symmetry index (BSI) from 129 women after breast surgery has been calculated by the first author with this new BAT® formula. The resulting BSI values of these 129 breast cancer patients were then correlated with subjective symmetry scores from the 18 observers using the Harris scale. The BSI of ten images was also calculated from five observers different from the first author to calculate inter-rater reliability. In a second phase, the new BAT® formula was validated and correlated with subjective scores of additional 50 women after breast surgery. RESULTS: The inter-rater reliability analysis of the objective evaluation by the BAT® from five individuals showed an ICC of 0.992 with almost no difference between different observers. All subjective scores of 50 patients correlated with the modified BSI score with a high Pearson correlation coefficient of 0.909 (p < .001) which was better compared to the old software (r = 0.769; p < .001). CONCLUSIONS: The modified BAT® software improves the correlation between subjective and objective BSI values, and may be a new standard for trials evaluating breast symmetry.

Influence of resection extent on morbidity in surgery for squamous cell cancer at the pharyngoesophageal junction.

PURPOSE: Squamous cell cancer (SCC) of the pharyngoesophageal junction area has a poor prognosis mainly due to late symptom manifestation and diagnosis. Treatment of choice is still pharyngolaryngoesophagectomy, substantially affecting quality of life. Limited surgical procedures have been adopted as well. The aim of this retrospective study was to evaluate whether the extent of resection influences postoperative safety and mortality. METHODS: From 1984 to 2006, 66 patients were operated at a single tertiary referral center. Nineteen patients (28.8 %) had SCC of the hypopharynx and 47 patients (71.2 %) had SCC of the cervical and cervicothoracic esophagus. Thirty-five patients (53.0 %) underwent cervical esophageal resection (CE) and 31 underwent total esophagectomy (TE). In 39 patients (59.1 %), the larynx was preserved. Thirteen patients (19.7 %) underwent multimodal treatment. RESULTS: Overall postoperative morbidity was 69.7 % and reoperation rate reached 28.8 %. TE (P = 0.03) and larynx preservation (P = 0.02) were followed by a higher rate of non-lung infections compared with CE and pharyngolaryngectomy, respectively. Pulmonary complications have been observed more frequently after larynx preservation (P = 0.02). Hospital mortality was 9.1 %. Four patients died after TE (12.9 %) and two patients died after CE (5.7 %). In all of them, the larynx had been preserved (15.4 %). Overall, 53 patients (80.3 %) died until follow-up. One-year and 5-year survival in patients with the major tumor burden at the cervicothoracic site was 35.7 and 0 %. CONCLUSIONS: CE can be recommended as long as R0 resection is warranted. The advantage of larynx preservation is gained by higher morbidity and mortality rates and may not be recommended as standard procedure. Surgery may not be appropriate for advanced SCC in the cervicothoracic region.

Chronic Fistulas of Thigh Presenting Unusually in an Operated Patient of Carcinoma Rectum. More Than What Meets the Eye!

Chronic skin lesions of the thigh (wounds, fistulas etc) are relatively uncommon, vis-à-vis, their notorious cousins over the distal limb. Even when present, the cause is usually obvious, mostly as trauma or a systemic affliction. We present an unusual case of chronic fistulas over the right thigh in a patient of carcinoma rectum for which anterior resection and an end colostomy was done 4 years earlier. Postsurgical pelvic abscesses finding their way into the thigh are a known entity, but they are usually accompanied by systemic/local features and their presentation is within a shorter time span. The novelty of our case lies in its manifestation (as a cluster of chronic fistulas and not a frank abscess), its late presentation as well as in the absence of any systemic/local inflammatory signs. Our primary objective is to educate wound physicians about the origin of such fistulas whenever they deal with patients who have had a preceding surgical intervention of the abdomen. In our humble opinion, this will ease out many diagnostic and management dilemmas, that such patients can potentially pose.

Adjunctive homeopathic treatment of hospitalized COVID-19 patients (COVIHOM): A retrospective case series.

BACKGROUND: and purpose. COVID-19 is a novel viral disease causing worldwide pandemia. The aim of this study was to describe the effect of adjunctive individualized homeopathic treatment delivered to hospitalized patients with confirmed symptomatic SARS-CoV-2 infection. PATIENT PRESENTATION: Thirteen patients with COVID-19 were admitted. Mean age was 73.4 ± 15.0 (SD) years. Twelve (92.3%) were speedily discharged without relevant sequelae after 14.4 ± 8.9 days. A single patient admitted in an advanced stage of septic disease died in hospital. A time-dependent improvement of relevant clinical symptoms was observed in the 12 surviving patients. Six (46.2%) were critically ill and treated in the intensive care unit (ICU). Mean stay at the ICU of the 5 surviving patients was 18.8 ± 6.8 days. In six patients (46.2%) gastrointestinal disorders accompanied COVID-19. CONCLUSION: The observations suggest that adjunctive homeopathic treatment may be helpful to treat patients with confirmed COVID-19 even in high - risk patients especially since there is no conventional treatment of COVID-19 available at present.

Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis.

BACKGROUND AND AIMS: Tertiary peritonitis is a severe persisting intra-abdominal infection and associated with high mortality. The aim was to find significant risk factors for mortality and tertiary peritonitis including the Mannheim Peritonitis Index (MPI), the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and a sumscore of both. MATERIALS AND METHODS: In this retrospective single-center cohort study, 122 patients were treated at the Surgical Department of a University Hospital. RESULTS: Sixty-nine patients (56.6%) developed tertiary peritonitis. Nineteen patients (27.5%), who suffered from tertiary peritonitis, died in contrast to eight patients (15.1%) with secondary peritonitis (P = 0.101). Patients with tertiary peritonitis had significantly higher APACHE II (P < 0.001), MPI (P = 0.035), and combined APACHE II and MPI scores (P < 0.001) than patients with secondary peritonitis. Age (P = 0.035), fungal infections (P = 0.025), and infections with more than one microbial organism (P = 0.047) were predictive for tertiary peritonitis. Combined APACHE II and MPI scores detected tertiary peritonitis better than the MPI (P = 0.014). Detection of mortality was comparable in all evaluated prognostic scores. CONCLUSION: Prognostic scores besides age and fungal infections are risk factors for mortality and help to differentiate between secondary and tertiary peritonitis. The combination of prognostic scores is comparable to the APACHE II and superior compared to the MPI in regard to detection of tertiary peritonitis.

Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy.

BACKGROUND: With promising short-term results, laparoscopic sleeve gastrectomy (SG) has become the second most frequently performed bariatric procedure worldwide. Aside from a growing number of reports covering up to 10 years of follow-up, only limited data have been published so far on long-term results. OBJECTIVES: The aim of the study was to present a 10-year follow-up for SG. SETTING: University hospital setting, Austria. METHODS: We present the first complete 10-year follow-up of 53 consecutive patients who underwent SG before 2006. In this multicenter study, weight loss success, weight regain, and revisional surgery were analyzed beside Bariatric Analysis and Reporting Outcome System (BAROS) scores. RESULTS: A mean maximum percent excess weight loss of 71±25% (percent total weight loss: 28±15%) was reached at a median of 12 (range 12-120) months after SG. At 10 years, a mean percent excess weight loss of 53±25% was achieved by 32 patients, corresponding to a percent total weight loss of 26.3±13.4%. Nineteen of the 53 patients (36%) were converted to Roux-en-Y gastric bypass (n = 18) or duodenal switch (n = 1) due to significant weight regain (n = 11), reflux (n = 6), or acute revision (n = 2) at a median of 36 months. Two patients died at 3 and 101 months postoperatively, unrelated to SG. A total of 31 patients (59%) suffered from weight regain of 10 kg or more, among them 24 patients (45%) with 15 kg or more, 16 patients (30%) with 20 kg or more, and 7 patients (13%) with 25 kg or more weight regain from nadir. Mean BAROS score was 2.4±2.2 at 10 years follow-up, classifying SG as "fairly efficient." CONCLUSION: Within a long-term follow-up of 10 years or more after SG, a high incidence of both significant weight regain and intractable reflux was observed, leading to conversion, most commonly to Roux-en-Y gastric bypass.

Effect of endoscopic thoracic sympathetic block on plantar hyperhidrosis.

HYPOTHESIS: Endoscopic thoracic sympathetic block at T4 (ESB4) provides excellent results in patients with primary hyperhidrosis (HH) of the upper limb. Most patients have combined palmo-plantar or palmo-axillary-plantar HH. This study evaluates the clinical outcome of patients with upper limb HH with special emphasis on plantar sweating and patients' quality of life. DESIGN: Review of a prospectively gathered database. SETTING: Tertiary care university teaching hospital. PATIENTS: The cohort included 73 patients (50 women and 23 men; mean age, 30.2 years). Twenty-six patients had palmar; 3, isolated axillary; and 44, combined HH. Sixty-six patients (90.4%) had concomitant plantar HH. INTERVENTIONS: One hundred forty-five operations were performed by applying one 5-mm clip above and below the fourth sympathetic ganglion. RESULTS: Of palms, 71.9% were completely and 28.1% were nearly dry. Corresponding percentages were 45.1% and 50.5% for armpits and 4.5% and 37.9% for the soles, respectively. Of soles, 42.4% remained unchanged and 15.2% became slightly worse. Compensatory sweating occurred in 19.4% of patients, with 2.8% having severe compensatory sweating. Feet were rarely affected by compensatory sweating (5.6%). Gustatory sweating was reported by 31.9% of patients but did not bother them. Quality of life improved significantly after ESB4. Most patients (87.5%) were completely satisfied with the outcome; 9.7% were partly satisfied. CONCLUSIONS: In the treatment of upper limb HH, ESB4 yields excellent success rates. Plantar sweating can be relieved in nearly half of patients, although exact neurophysiologic mechanisms remain unclear. Incidence of compensatory and gustatory sweating is low, contributing to a high patient satisfaction and improvement in quality of life.

Postoperative CMF Does Not Ameliorate Poor Outcomes in Women With Residual Invasive Breast Cancer After Neoadjuvant Epirubicin/Docetaxel Chemotherapy.

BACKGROUND: Neoadjuvant chemotherapy (NACT) is an accepted treatment approach in early-stage breast cancer. In contrast, the potential role of postneoadjuvant chemotherapy after taxane-containing NACT remains unclear. The aim of this study was to evaluate postneoadjuvant chemotherapy and further prognostic factors that predict outcome in women without pathologic complete remission (pCR). PATIENTS AND METHODS: A total of 377 patients with breast cancer who received preoperative chemotherapy were included in this retrospective study. Patients without standard NACT (6 cycles of epirubicin with docetaxel) or primary metastatic breast cancer and locally advanced, inoperable cancer were excluded from further analysis (n = 186). This resulted in a study population of 191 women (30 [15.7%] with pCR; 161 [84.3%] without pCR). Major outcome parameters were event-free survival (EFS) and overall survival (OS). The following parameters were tested for their prognostic role: postneoadjuvant chemotherapy, patient age, breast cancer subtype (luminal/HER2-negative tumors, HER2-positive tumors, and triple-negative tumors), histological grade, pCR, residual lymph node invasion, and residual invasive tumor size. RESULTS: At a median follow-up of 54 months, 51 disease relapses (26.7%) and 21 deaths (11%) were observed. In a comparison of patients with pCR with those without, no significant differences in EFS or OS were observed. Postneoadjuvant chemotherapy was significantly associated with shorter OS in patients without pCR. CONCLUSION: In this population, which included a high percentage of patients with luminal cancers, pCR did not predict for improved OS. Postneoadjuvant chemotherapy showed no discernible benefit even in subgroups with aggressive tumor biology or significant remaining tumor burden. The use of such treatment should therefore be discouraged outside of clinical trials.

Quality of life after sympathetic surgery at the T4 ganglion for primary hyperhidrosis: clip application versus diathermic cut.

INTRODUCTION: Limited procedures at the T4 ganglion show low rates of compensatory sweating (CS). The aim of the study was to compare endoscopic sympathetic block (ESB) via clip application with endothoracic sympathicotomy (ETS) via diathermy with special regard on patients' quality of life (Qol). PATIENTS AND METHODS: Treatment success, side effects and patient satisfaction were evaluated in a prospectively gathered database of a tertiary-care referral hospital. Two disease-specific Qol questionnaires were used (Keller, Milanez de Campos). RESULTS: 406 operations were performed in 205 patients (ESB4 N = 114, ETS4 N = 91) with a median follow-up of 12 months. Both procedures improved Qol significantly (P < 0.001) and the degree of improvement was equal in both groups. Palmar and axillary HH were ameliorated after both procedures (P < 0.001). Accordingly, plantar HH decreased after ESB4 (P = 0.002), while remaining unaltered after ETS4. Nineteen patients (9.3%) reported CS and 10 patients (4.9%) judged it as "disturbing". Nine of the latter belonged to the ETS4 group compared to one ESB patient (P = 0.015). Patients developed higher rates of plantar CS after ETS4 compared to ESB4 (P = 0.006). Five patients (2.4%) from both cohorts reported persistence of axillary HH. Recurrence of axillary symptoms was found in 5 ESB4 patients. Satisfaction rates did not differ significantly. CONCLUSION: Patients' Qol and satisfaction rates are similar in both treatment groups for upper limb HH. Outcome and recurrence rates speak in the favor of ETS4, severity of CS and potential reversibility argue for ESB4.

Standardization of morbidity assessment in breast cancer surgery using the Clavien Dindo Classification.

INTRODUCTION: There are no published data on standardized scoring systems for morbidity after breast cancer surgery. Aim of the study was to establish the Clavien Dindo Classification (CDC) as assessment tool and to identify risk factors for morbidity after breast surgery investigating new techniques including oncoplastic surgery and neoadjuvant chemotherapy. PATIENTS AND METHODS: Between 2008 and 2010, data were retrospectively evaluated from 485 women with breast cancer who underwent surgery at a university hospital. The CDC was used to assess the severity of postoperative complications. Multivariable analyses were adjusted by body-mass index, smoking, diabetes mellitus and tumour size. RESULTS: Overall complications (CDC 1-4) were reported in 28.7%. Second surgery related to major complications (CDC 3-4) was mandatory in 4.7%. Axillary dissection was an independent predictor for CDC 1-4 in all patients (P = 0.008, OR of 1.81, 95%CI 1.17-2.82). We found no independent predictor for CDC 3-4. Oncoplastic surgery increased the rate of wound infections (P = 0.010, OR: 2.94, 95%CI 1.30-6.67) and necroses (P < 0.001, OR: 8.38, 95%CI 3.28-21.4). Axillary dissection elevated wound infection (P = 0.040, OR: 2.07, 95%CI 1.03-4.14) and seroma rates (P < 0.001, OR: 2.46, 95%CI 1.51-4.01). Neoadjuvant chemotherapy had no impact on morbidity. CONCLUSION: The CDC is a valid assessment tool for future clinical trials and may be useful for hospital quality control. While axillary dissection and oncoplastic surgery raised morbidity, no single factor predicted for morbidity related second surgery.

Adjuvant bisphosphonates in endocrine-responsive breast cancer: what is their place in therapy?

Recent advances in the treatment of early breast cancer have improved clinical outcomes and prolonged survival, especially in women with endocrine-responsive disease. However, cancer therapies including cytotoxic chemotherapy, ovarian suppression, and aromatase inhibitors can drastically reduce circulating estrogen, increasing bone loss and fracture risk. Because most women with early breast cancer will live for many years, it is important to protect bone health during cancer therapy. Several recent clinical trials combining adjuvant endocrine therapy with bisphosphonates have demonstrated efficacy for preventing cancer treatment-induced bone loss in pre- and postmenopausal women with early breast cancer. The largest body of evidence supporting the use of adjuvant bisphosphonates comes from studies with zoledronic acid; however, studies with risedronate, ibandronate, and denosumab (a biologic agent) have also demonstrated efficacy for preventing bone loss. Adding zoledronic acid to endocrine therapy prevents bone loss and improves bone mineral density (BMD). In addition, preclinical studies suggest that bisphosphonates have direct and indirect antitumor activity, such as inducing tumor cell apoptosis, reducing tumor cell adhesion and invasion, reducing angiogenesis, activating immune responses, and synergy with chemotherapy agents, among others. Clinical trials have demonstrated significantly improved disease-free survival in patients receiving adjuvant endocrine therapy plus zoledronic acid compared with endocrine therapy alone. Ongoing studies will further define the role of adjuvant bisphosphonates in maintaining bone health and improving clinical outcomes. The available evidence suggests that pre- and postmenopausal patients may receive clinical benefit from including bisphosphonates as part of their adjuvant treatment regimen for endocrine-responsive early breast cancer.

Is Endocrine Therapy Really Pleasant? Considerations about the Long-Term Use of Antihormonal Therapy and Its Benefit/Side Effect Ratio.

Endocrine therapy has become a key part in the adjuvant treatment of hormone responsive breast cancer. The positive effect on relapse risk reduction is well defined, but therapy is not free from bothersome side effects for which estrogen deprivation accounts to a great extent. Since endocrine therapy is usually prescribed for 5 years or longer to optimally display its protective effect, and because physical strain is missing, good tolerability and safety properties are important, particularly in low-risk patients. While tamoxifen has been the standard adjuvant endocrine treatment with well documented efficiency, it is increasingly replaced by third generation aromatase inhibitors due to their better effectiveness and tolerability. Because tamoxifen holds a risk for life-threatening adverse events such as endometrial cancer, pulmonary embolism, and stroke, its recommended duration of therapy is limited to 5 years, also because extension beyond that time did not produce a measurable advantage. While some side effects are present both with tamoxifen and aromatase inhibitors, differences in side effect profiles are well established. Although side effects of aromatase inhibitor-related therapy usually are mild and common to symptoms of menopause, misconception of the symptoms and their mechanism of action, as well as lack of knowledge about how to handle them, can easily lead to dangerous discontinuation of therapy.