Does the breast reconstruction method have an impact on time delay to adjuvant chemotherapy - A comparison between autologous and expander/implant breast reconstruction.

Introduction: This study aims to analyze whether autologous breast reconstruction as compared to expander/implant reconstruction has a higher risk of postoperative wound healing problems (WHPs) and thus potentially delays chemotherapy start. Methods: Between January 2012 and December 2019, a total of 64 women with NSME/SSME and autologous (Group1, n = 33) or expander/implant reconstruction (Group2, n = 31) and adjuvant chemotherapy were enrolled in this study conducted at Innsbruck Medical University Hospital. Immediate postoperative WHPs in each group were compared, and the time from operation to initiation of chemotherapy was analyzed. If the start of chemotherapy was postponed for more than six weeks postoperatively due to WHP, it was defined as delayed. Statistical analysis was performed with SPSS and Fisher's exact test. Results: More postoperative WHP occurred in Group 1 than in Group 2 (51.6% vs. 9.7%, p < 0.001). Due to WHP, chemotherapy start was delayed for more than six weeks postoperatively in 30.3% of Group 1 patients and 3.2% of Group 2 patients. Only small differences in age (Group 1: 47±1 vs. Group 2: 46±2 years) and BMI (Group 1: 24.3 ± 0.6 vs. Group 2: 23.3 ± 0.7 kg/m2) were found. Conclusion: Our study shows a far smaller risk for postoperative WHP and delay of chemotherapy start in the expander/implant group in comparison with the autologous group. In some selected patients with high urgency for adjuvant chemotherapy, a bridging operation by means of expander reconstruction prior to chemotherapy could be an oncologically safe pathway.

Influence of Incision Site on Postoperative Outcome in Skin-/Nipple-Sparing Mastectomy: Is There a Difference between Radial and Inframammary Incision?

BACKGROUND: The aim of this study was to determine whether there is a difference in results between the radial and the inframammary approach in nipple-/skin-sparing mastectomy and immediate reconstruction. METHODS: The patients were divided into two groups (group 1: radial incision; group 2: inframammary fold incision [IMF]), each consisting of two subgroups for direct-to-implant reconstruction (1a, 2a) and expander reconstruction (1b, 2b). The patients were operated on between March 2012 and May 2017. Preoperative tumor parameters, reconstruction parameters, postoperative tumor parameters, and immediate and late complications were assessed. Postoperative photographs were evaluated by the patients and 8 plastic surgeons by means of grading (1-5) and the visual analog scale (VAS; 1-10). RESULTS: Enrolled in this study were 28 patients, namely, 7 patients in each subgroup. The median age was 46 years, and the median follow-up period was 40 months. No immediate complications occurred. Three patients had late complications, but there was no case of evident capsular fibrosis. Twenty-seven patients (96.42%) evaluated the postoperative result as excellent/good. The postoperative evaluation by the plastic surgeons was excellent/good for a median of 18 patients (64.28%). Group 1 showed a median VAS score of 7.63 (expander group: 7.50; direct-to-implant group: 7.75); the median VAS score for group 2 was 8.25 (expander group: 8.75; direct-to-implant group: 7.50). CONCLUSIONS: Our study shows good results for implant breast reconstruction in both groups, with minimally better results for the IMF group. In the direct-to-implant subgroups, the radial group showed slightly better results.

Therapeutic management and outcome of locoregional recurrence after curative colorectal cancer therapy-a single-center analysis.

Locoregional tumor recurrence after curative therapy for colorectal cancer is therapeutically challenging and associated with poor prognosis. Goal of this single-center study was to analyze patients with locoregional recurrence with regard to therapeutic strategies and outcome for colon and rectal cancer each. Charts of all patients surgically treated for colorectal cancer in the period from 2000 to 2011 (n = 1296) were examined; patients with locoregional recurrence (n = 86) were then further analyzed. Fifty-three (10.2%) patients with rectal and 33 (5.6%) patients with colon cancer developed a locoregional recurrence, median 24.5 months after first diagnosis. Recurrence-specific therapy was applied in the majority of the patients (84.8% colon, 90.7% rectum); a surgical approach was undertaken in 82.1% (colon) and in 56.3% (rectum). Five-year overall survival after locoregional recurrence was 13% for rectal cancer and 9% for colon cancer. Itemized analysis for the approached therapeutic regimens revealed that radical recurrence resection (R0) significantly prolongs overall survival (p = 0.003) in rectal cancer, as does a surgical approach itself, as compared to conservative treatment modalities. If feasible, oncologic radical resection of the relapse (R0) significantly influences patient outcome and overall survival in rectal cancer.

Is limited surgery justified in the treatment of T1 colorectal cancer?

BACKGROUND: Surgical treatment of colorectal cancer (CRC) should be aimed primarily at achieving a combination of surgical-oncologic radicalness and the highest possible quality of life. In recent years, surgical therapy for T1 CRC has tended toward less radical interventions. The question regarding changes in survival and recurrence rates still is unanswered. METHODS: A retrospective medical chart review of patients surgically treated in our department for T1 CRC from January 1990 to December 2010 (n = 223) was performed. Charts were reviewed for tumor-specific parameters, local recurrence, distant metastasis, and patient survival. The different treatment options used were strictly separated for a more detailed workup. RESULTS: Radical resection (RR) was performed for 57.1 %, local resection (LR) for 14.8 %, and an endoscopic approach (EA) for 28.1 % of the study population. After receipt of the histology report, 35.7 % of the patients initially resected nonradically underwent reoperation, mostly using RR. Seven patients experienced a local recurrence over time (3.6 %): one after initial RR, three after LR, and three after EA. Systemic recurrence occurred for nine patients (4.6 %) over time, six of whom had undergone initial RR. High-risk criteria were shown for 20 T1 CRCs. For 60 % (12/20) of the patients, initial RR was performed. Radical reoperation was performed for 75 % of the nonradically treated high-risk tumors. One high-risk patient without reoperation experienced metastatic disease over time. The 5-year overall survival rate was 87.2 %, itemized for the defined subgroups as follows: 83.9 % for RR, 82.8 % for LR, and 58.2 % for EA. CONCLUSION: Patients with T1 CRC had a distinctly higher incidence of local recurrence after EA or LR. Explicit workup in terms of risk classification is crucial to reducing the risk of local and systemic recurrence. A nonradical approach should be only a second option for patients with T1 CRC, namely, those solely in clearly low-risk situations or those with distinct comorbidities.

Incidence and predisposing factors of cold intolerance after arterial repair in upper extremity injuries.

OBJECTIVE: The purpose of this report was to present abnormal posttraumatic cold intolerance in patients that previously underwent repair of arterial injuries after civilian upper limb trauma in our institution. METHODS: All patients who underwent repair of arterial lesions after upper limb trauma since 1990 were reviewed, and clinical follow-up studies were performed. Patients were asked to complete the cold intolerance symptom severity (CISS) questionnaire to evaluate presence and severity of self-reported cold sensitivity, and the disabilities of arm, shoulder, and hand (DASH) questionnaire to analyze functional disability. Abnormal cold intolerance was defined as a CISS score over 30. Further analysis included evaluation of epidemiologic, clinical, and perioperative data for factors predisposing to abnormal cold intolerance. RESULTS: A total of 87 patients with previous repair of upper limb arterial injuries were eligible to answer the CISS and DASH questionnaires, and 56 patients (64%; 43 men; median age: 31.9 years) completed both. In our cohort, blunt trauma was the predominant cause of injury (n = 50; 89%). Accompanying lesions of nerves (n = 22; 39%) and/or orthopedic injuries (n = 36; 64%) were present in 48 patients (86%). After a median follow-up period of 5.5 years (range, 0.5-19.7), 23 patients (41% of 56) reported on abnormal cold intolerance. Patients with cold intolerance had worse functional results (as measured by the DASH questionnaire; mean ± SD, 42.7 ± 29.7 vs 11.5 ± 23.9; P < .001) when compared with patients without. Cold intolerance was more frequently seen in patients with previous nerve lesion (P = .027) and in proximal injuries (subclavian or axillary vs brachial or forearm arteries: P = .006), but was not correlated to gender, age, involvement of the dominant or nondominant arm, and the presence of ischemia, bone injury, or an isolated vascular injury. CONCLUSIONS: Abnormal cold intolerance is frequently seen in patients with a history of arterial repair in upper limb trauma. It is associated with significant functional impairment. Concomitant nerve injury and involvement of the subclavian or axillary artery are the major predisposing factors for development of cold intolerance after upper limb trauma.

Tacrolimus monotherapy following alemtuzumab induction in combined kidney-pancreas transplantation: results of a prospective randomized trial.

BACKGROUND: We investigated the safety and efficacy of Campath induction and tacrolimus (TAC) maintenance therapy compared to ATG induction with TAC +MMF + steroids in de novo kidney-pancreas transplanted patients. MATERIAL/METHODS: 14 patients (Group A) received Campath 30 mg + methylprednisolone 500 mg before revascularization followed by TAC monotherapy, and 16 patients (Group B) ATG 8 mg/kg with TAC + MMF+ steroids (withdrawn at month 3). TAC trough levels (ng/mL) of 12-15 were aimed for in both groups until month 6 and thereafter 6-12. RESULTS: 1-year patient survival was 100% in both groups; kidney and pancreas survival in Group A was 93% each. In Group B 1-year kidney and pancreas survival was 100% and 87%, respectively. A total of three pancreas grafts were lost due to thrombosis of the graft vein within the first month. The only kidney loss was due to initial non-function. All biopsy-proven acute rejections of renal transplants (n=3 in Group A, n=0 in Group B) were reversible. No acute pancreas graft rejection was demonstrated. Infectious complications, lipid metabolism and blood pressure were comparable in both groups, as were other adverse events. No tumor occurred. At 12 months 13 patients in each group were steroid-free; the mean serum creatinine level was 1.44 mg/dL in Group A and 1.33 mg/dL in Group B. All patients were exogenous insulin-free. CONCLUSIONS: At one year efficacy and safety of Campath +TAC monotherapy were comparable to those of ATG + TAC + MMF + steroids in a limited number of combined kidney-pancreas transplant recipients.

Single shot of alemtuzumab as induction therapy after kidney transplantation is sufficient.

In an earlier study, we were able to show that Tac monotherapy following 2 × 20 mg alemtuzumab induction is at least as effective as Tac-based triple-drug immunosuppression in cadaveric renal transplantation. We were interested to learn whether 1 × 30 mg of alemtuzumab is as effective as 2 × 20 mg. Patients of the initial study group (group A) received 20 mg alemtuzumab on days 0 and 2, and tac monotherapy from day 2 on. This group acted as control group for the new arm (group C), where patients were given only 1 × 30 mg alemtuzumab on day 0 followed by Tac monotherapy from day 2 on with the same target levels as in the control group. Frequency of rejection at 6 months was 15% in the control group compared to 6% in the study group and 20% at 12 months in group A versus 6% in group C (P = 0.034). Time to rejection was 4.9 months in group A and 0.8 in group C. One-year patient survival was 98.5% in both groups, graft survival 96.9% in group A, and 98.5% in group C. Safety profile was similar in both groups apart from more viral and bacterial infections in group C. Single shot alemtuzumab induction of 30 mg is as effective as 2 × 20 mg in cadaveric renal transplantation.

Long-term results and complications following adjustable gastric banding.

This study was performed to assess our long-term results with laparoscopic gastric banding in patients with an observation period of at least 9 years calculated from the date of operation. Between January 1996 and December 2000, a total of 276 patients (83% female) underwent laparoscopic gastric banding at our institution. Mean preoperative body mass index (BMI) was 44 +/- 6 kg/m(2). BMI after 1, 5, 7, 9, and 10 years was 33 +/- 6, 30 +/- 6, 31 +/- 6, 32 +/- 7, and 31 +/- 7 kg/m(2), respectively. Mean excess weight loss after 1 year was 57.1 +/- 23.0% and after 5, 7, 9, and 10 years 73.2 +/- 29.6%, 65.9 +/- 29.3%, 61.8 +/- 32.8%, and 64.0 +/- 32.1%, respectively. Median completeness of follow-up was 80%. Of the study population, 146 (52.9%) patients had at least one complication requiring reoperation. Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. Thirty-three patients had no second bariatric operation, a Roux-en-Y gastric bypass was done in 39 patients, and six patients underwent sleeve gastrectomy. Our long-term results are good with regard to weight loss in those patients who still have their band in situ. This is accompanied by a high complication rate and a 29% band loss rate.

CT-MIBI-SPECT image fusion predicts multiglandular disease in hyperparathyroidism.

BACKGROUND: To perform focused or minimally invasive surgery for hyperparathyroidism (HPT) exact preoperative localization is mandatory. Computed tomography-(99m)Tc-sestamibi-single photon emission computed tomography image fusion (CT-MIBI-SPECT) serves this difficult task in single gland HPT to a large extent. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone and CT alone in detecting abnormal parathyroid tissue in patients with multiglandular disease. PATIENTS AND METHODS: CT-MIBI-SPECT image fusion for preoperative localization was performed in 30 patients with multiglandular disease. There were six patients with primary hyperparathyroidism (four MEN I syndromes and two double adenomas; one of these patients has HRPT2 gene mutation), 14 with secondary, and eight with tertiary HPT, further one patient each suffering from persistent primary and persistent secondary hyperparathyroidism. In both persistent patients only one remaining gland was left from primary surgery. The results of MIBI-SPECT, CT, and CT-MIBI-SPECT image fusion were compared in these patients. The outcome and the exact predicted positions were correlated with intraoperative findings. RESULTS: In five out of six patients with multiglandular primary hyperparathyroidism more than one gland was detected, thus multiglandular disease could be suspected preoperatively. Overall CT-MIBI-SPECT image fusion was able to predict the exact position of all abnormal glands per patient in 14 of 30 (46.7%) cases, whereas CT alone was successful in 11 (36.7%), and MIBI-SPECT alone just in four (13.3%) of 30 patients. CONCLUSION: Multiglandular disease in primary hyperparathyroidism can be suspected preoperatively in a high percentage of patients. Additionally, this study shows that CT-MIBI-SPECT image fusion is superior to CT or MIBI-SPECT alone in preoperative localization of all pathologic glands in patients suffering from multiglandular disease.

Virtual neck exploration: a new method for localizing abnormal parathyroid glands.

BACKGROUND DATA: Computed tomography (CT) together with 99mTc-sestamibi single photon emission computed tomography (MIBI-SPECT) image fusion (CT-MIBI-SPECT image fusion) allows virtual exploration of the neck. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT and CT in detecting abnormal parathyroid glands in patients with primary hyperparathyroidism. METHODS: CT-MIBI-SPECT image fusion for preoperative localization was performed in 116 patients with primary hyperparathyroidism (pHPT). Both investigations were performed with reproducible fixation of the patient on a vacuum mattress. At a special work station the neck was virtually explored by viewing the CT images in all 3 dimensions. The MIBI-SPECT images were superimposed on underlying CT images. Only patients with single-gland disease were evaluated (pHPT: 112, persistent pHPT: 1, recurrent pHPT: 1, persistent secondary hyperparathyroidism: 1, tertiary HPT after kidney transplantation: 1). CT-MIBI-SPECT image fusion results were compared with those obtained with CT alone and MIBI-SPECT alone. The predicted positions were correlated with the intraoperative findings. RESULTS: CT-MIBI-SPECT image fusion was able to predict the exact position of the abnormal gland in 102 (88%) of the 116 patients, whereas CT alone showed in 75 (65%) patients and MIBI-SPECT alone in 64 (55%) patients the exact position of the abnormal gland. Sixty-two patients underwent minimally invasive surgery, namely in 21 patients with a unilaterally focused approach and in 33 patients with a bilateral approach (27 of these underwent simultaneous thyroid resection). Sensitivity for CT-MIBI-SPECT image fusion was 88%, for CT alone 70%, and for MIBI-SPECT alone 59%. Specificity for CT-MIBI-SPECT image fusion was 99%, for MIBI-SPECT alone 95%, for CT alone 94%. Overall accuracy for CT-MIBI-SPECT image fusion was 97%, for CT alone 89%, for MIBI-SPECT 87%. CONCLUSIONS: This study provides evidence that CT-MIBI-SPECT image fusion is superior to CT or MIBI-SPECT alone for preoperative localization of enlarged parathyroid glands in patients with single-gland primary hyperparathyroidism.

Results and complications after Swedish adjustable gastric banding-10 years experience.

BACKGROUND: Bariatric surgery is currently the only effective treatment for morbid obesity. The main advantage of laparoscopic adjustable gastric banding is that this operation is minimally invasive to the stomach and adjustable to the patient's needs. Few long-term studies on Swedish adjustable gastric banding (SAGB) have been published. We here report our 10-year experience with 785 SAGB procedures. METHODS: Between January 1996 and January 2006, 785 consecutive patients (81% women, 19% men) underwent laparoscopic SAGB. All data (demographic and morphologic, operative, and annual follow-up data) were prospectively collected in a computerized data bank. The postoperative follow-up program was performed largely by residents while 30 different surgeons performed the operation. RESULTS: Follow up data were available for 733 patients (98.3%); 52 patients (6.6%) were lost to follow-up. The median follow-up was 3.0 years (range, 1-10 years). The median total weight loss was 26 kg after 1 year and 40.5 kg after 8 years with a median EWL of 65.5% after 8 years. The median BMI decreased from 42.9 to 28.3 kg/m2. A total number of 688 complications occurred in 396 patients (50.4%). The most common complications were esophagitis (28.8%), pouch dilation (15.3%), esophageal dilation (12.5%), port problems (11%), band migration (6.5%), and band leakage (6.4%). Overall, 251 reoperations (32%) were performed. There was no mortality. CONCLUSIONS: From our 10-year experience, we can state that SAGB is an effective bariatric procedure for achieving weight loss. Because of the high complication and reoperation rate, it is necessary to select patients according to specific criteria for gastric banding.

Target registration and target positioning errors in computer-assisted neurosurgery: proposal for a standardized reporting of error assessment.

BACKGROUND: Assessment of errors is essential in development, testing and clinical application of computer-assisted neurosurgery. Our aim was to provide a comprehensive overview of the different methods to assess target registration error (TRE) and target positioning error (TPE) and to develop a proposal for a standardized reporting of error assessment. METHODS: A PubMed research on phantom, cadaver or clinical studies on TRE and TPE has been performed. Reporting standards have been defined according to (a) study design and evaluation methods and (b) specifications of the navigation technology. RESULTS: The proposed standardized reporting includes (a) study design (controlled, non-controlled), study type (non-anthropomorphic phantom, anthropomorphic phantom, cadaver, patient), target design, error type and subtypes, space of TPE measurement, statistics, and (b) image modality, scan parameters, tracking technology, registration procedure and targeting technique. CONCLUSIONS: Adoption of the proposed standardized reporting may help in the understanding and comparability of different accuracy reports.

Disappointing mid-term results after laparoscopic gastric banding in young patients.

BACKGROUND: When gastric banding was introduced as a bariatric operation about 12 years previously, its early results were promising, with a low complication rate. Only a few long-term studies on this subject have been published. This study was performed to assess our results with laparoscopic gastric banding in young patients after

Virtual neck exploration in patients with hyperparathyroidism and former cervical operations.

BACKGROUND: In surgery for primary hyperparathyroidism, preoperative localization together with intraoperative parathyroid hormone assay is important when minimal invasive operations of the parathyroid glands are intended. In cases of reoperation, correct localization of the abnormal parathyroid glands is extremely instrumental. Computed tomography (CT)-(99m)Tc-sestamibi (MIBI)-single photon emission computed tomography (SPECT) image fusion allows for a virtual exploration of the neck by showing the suspected gland three-dimensionally with all the anatomic landmarks in correct position. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone in detecting abnormal parathyroid glands in patients with previous neck surgery. PATIENTS AND METHODS: In a prospective study, CT-MIBI-SPECT image fusion for preoperative localization was performed in 28 patients with hyperparathyroidism and previous neck surgery. Twenty-one patients had thyroidectomy and seven patients had surgery for hyperparathyroidism. The results of MIBI-SPECT alone and CT-MIBI-SPECT image fusion were compared in these patients. The outcome and the exact predicted position, not just the predicted side, were correlated with intraoperative findings. RESULTS: CT-MIBI-SPECT image fusion was able to predict the exact position of the abnormal gland in 24 of 28 patients (86%), whereas MIBI-SPECT alone was successful in 12 of 28 cases (43%, p < 0.004) only. CT-MIBI-SPECT image fusion detected all three pathologic glands in their ectopic position. With MIBI-SPECT alone, just one ectopic pathologic gland was found. CONCLUSION: This study provides evidence that CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone in preoperative localization of enlarged parathyroid glands in patients with hyperparathyroidism and previous neck surgery. This should be kept in mind if the results are compared to earlier studies concerning CT-MIBI-SPECT image fusion.

Protein levels of heme oxygenase-1 during reperfusion in human kidney transplants with delayed graft function.

INTRODUCTION: Delayed graft function (DGF) as a consequence of ischemia reperfusion injury (IRI) is associated with a decrease in long-term allograft survival. Heme oxygenase-1 (HO-1) is a stress responsive gene that is highly expressed in multiple pathological processes. The aim of our study was to analyze whether HO-1 protein levels in human kidney transplants during IRI correlate with the incidence of DGF. METHODS: Kidney biopsies were obtained from 27 kidney allografts at two time points: at the end of cold storage and shortly after reperfusion. Samples were analyzed for HO-1 protein levels by Western blot. RESULTS: Heme oxygenase-1 protein levels were significantly higher in post-reperfusion biopsies (39.4 vs. 13.7 arbitrary units, p = 0.001). In pre-reperfusion biopsies no association was observed between HO-1 protein levels and DGF. In post-reperfusion biopsies, higher levels of HO-1 protein were measured in kidneys with DGF (53.7 vs. 36.2 arbitrary units, p = 0.064). DGF kidneys showed a significantly higher increase from pre- to post-reperfusion in HO-1 protein (42.0 vs. 18.7 arbitrary units, p = 0.025). CONCLUSION: Heme oxygenase-1 protein levels shortly after allograft reperfusion are closely related with initial graft function. Assessment thereof may be considered a valuable tool to predict DGF.

A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis.

OBJECTIVE: The aim of this study was to analyze the effect of the surgical approach on surgical and neurologic outcomes after extended thymectomy for myasthenia gravis. METHODS: A retrospective analysis of the institutional extended thymectomies for myasthenia gravis within the last decade was performed. Patients of group A (open access by total median sternotomy; n=10; 1996-2002) and of group B (video assisted thoracoscopic surgery approach with the da Vinci robotic system; n=9; 2003-2006) did not differ with regard to gender distribution, age, body mass index, American Association of Anaesthetists score and Osserman classification of myasthenia gravis. Primary endpoints were surgical complications and the symptomatic/neurologic outcome of the extended thymectomy. Secondary endpoints were operating times and hospital stay. RESULTS: Median follow-up was 74+/-23 months in group A and 13+/-10 months in group B. Surgical complications occurred in 4 patients in group A (requiring 2 re-interventions) and in 1 patient in group B (p<0.05). The median dose of Pyridostigminbromid was reduced 3 and 6 months postoperatively in group A to 80% and 60% of the preoperative level and in group B to 66% and 60% of the preoperative level, respectively. Within the first postoperative year all patients of group B had an improvement of their disease whereas 2 patients of group A did not benefit from thymectomy or had a worsening of symptoms. Operating times were significantly shorter in group A (110 (42-152) min vs 154 (94-312) min, p<0.05), hospital stay was significantly shorter in group B (5 (4-15) vs 10 (10-23) days, p<0.05). CONCLUSIONS: The results of this small series favour the robotic approach for extended thymectomy for myasthenia gravis in respect of both surgical and early neurologic outcome. However, prospective randomized trials are required to prove a general validity.