Extremity soft tissue tumor surgery by surgical specialty: a comparison of case volume among oncology and non-oncology-designated surgeons.

INTRODUCTION: We sought to characterize the extent of extremity soft tissue tumor (ESTT) resections among surgical specialties, hypothesizing that substantial variation exists in the number of ESTT resections performed by specialty. METHODS: We queried the UHC-AAMC database for data from 85 institutions for years 2007-2009. We abstracted data on total number of musculoskeletal (MSK) procedures, number of subcutaneous (SQ), deep, and malignant ESTT resections, and anatomic site of resection. Data were available for 4,682 practitioners including the following specialties: general surgery (GS, N = 2,195), plastic surgery (PS, N = 792), surgical oncology (SO, N = 533), general orthopedics (GO, N = 1,079), and orthopedic oncology (OO, N = 83). RESULTS: The mean number of all MSK procedures performed per year was 19.0 ± 2.3 GS, 179.6 ± 3.0 PS, 32.4 ± 6.2 SO, 798.6 ± 115.4 GO, and 482.9 ± 6.5 OO (P = 0.001). SQ ESTT resections per year were similar among specialties (1.7 ± 0.3 GS, 2.7 ± 0.3 PS, 2.4 ± 0.4 SO, 1.7 ± 0.5 GO, 4.7 ± 0.2 OO), while deep and malignant resections were more likely performed by OO (combined deep and malignant: 0.9 ± 0.1 GS, 2.0 ± 0.4 PS, 9.9 ± 0.6 SO, 5.8 ± 0.3 GO, and 63.6 ± 8.1 OO, P = 0.001). Adjusting for number of physicians in the database, of the total deep and malignant ESTT resections, 9.4% were performed by GS, 7.7% by PS, 26.0% by SO, 30.8% by GO, and 26.0% by OO. CONCLUSION: Nearly 50% of deep and malignant ESTT resections are performed by non-oncology-designated surgeons. Approximately 17% are performed by practitioners who complete an average of one to two of these procedures per year. These findings may have significant implications for quality of care in soft tissue tumor surgery.

Successful management of cervicoesophageal anastomosis leak after microsurgical esophageal reconstruction: a case report and review of the literature.

Free visceral and, more recently, free fasciocutaneous flaps are becoming increasingly common for esophageal reconstruction. However, complications of free flap conduit ischemia, specifically anastomotic leak have not been frequently discussed in the literature. This article provides a detailed description of total esophageal reconstruction with an 18 x 8.5 cm tube free radial forearm flap. A clinically significant cervical anastomosis leak was contained and healed with an innovative surgical rearrangement of local muscle flaps and closed suction drainage. We discuss the literature associated with cervical anastomotic leaks after visceral reconstruction and adapt those principles to the unique physiology of free fasciocutaneous flaps to develop a simple but reliable salvage option. This approach should be considered by reconstructive surgeons when helping other surgeons to manage an anastomotic leak after a cervical esophageal reconstruction in a similar setting.

Experience and attitudes of surgeons toward palliation in cancer.

BACKGROUND: Surgery can effectively palliate symptoms in patients with advanced malignancy and thereby maintain quality of life. However, the goal of surgical palliation should be balanced with the associated risks, and the decision to operate can be challenging for even the most experienced surgeon. HYPOTHESIS: There are significant deficiencies in training during residency and in continuing medical education in palliative surgical care leading to a lack of agreement for treatment recommendations. DESIGN AND SETTING: A survey of general surgeons involving 4 clinical vignettes of patients with advanced malignancies and varying degrees of symptoms. Respondents were asked to select the best treatment option for each patient from a list of 6 alternatives. Furthermore, respondents identified the clinical factors that most influenced the decision, as well as the major goal of the palliative intervention. SUBJECTS: Surgeons in a midsized urban setting and its surrounding region. RESULTS: Of 124 surveys sent out, 70 (56%) were completed. Significant deficiencies in education were identified; 59 (84%) of the respondents did not receive any education in palliative surgical care during residency and 28 (44%) lacked continuing medical education. A consensus treatment recommendation was not selected in 3 of the 4 clinical vignettes, but the respondents used similar clinical factors and goals of treatment for selection of the specific recommendation. CONCLUSIONS: Palliative care is a major deficiency of postgraduate surgical training. A more focused effort in training surgeons in palliative care may allow for the more uniform and standard provision of palliative surgical care to patients with advanced cancer.

Extremity soft tissue sarcoma: controversial management issues.

Unlike common malignancies, such as breast and colorectal carcinoma, where treatment modalities can be investigated with large prospective randomized trials, such an endeavor has been hampered with soft tissue sarcomas (STS) due to its rarity. In absence of such randomized clinical trials, controversy exists with regards to numerous clinically relevant questions and clinicians are left with single institutional experiences gathered either in a retrospective or prospective fashion. Some of these frequently encountered issues in the management of STS include (1) whether poorly executed biopsies affect outcome? (2) Do all unplanned excisions require re-excisions? (3) Is MRI a superior imaging modality? (4) Whether radiation should be provided pre- or post-operatively? (5) Does extent of surgical margin influence local control? (6) Is adjuvant radiation therapy necessary for stage IIB STS? (7) Does adjuvant chemotherapy influence local control? (8) Does local recurrence influence survival? We will address these topics in this review.

Immediate breast reconstruction after mastectomy increases wound complications: however, initiation of adjuvant chemotherapy is not delayed.

BACKGROUND: Immediate breast reconstruction is being increasingly used after mastectomy, although it may increase the incidence of wound complications. The indications for chemotherapy in breast cancer are expanding and wound complications following mastectomy may delay the initiation of adjuvant chemotherapy. HYPOTHESIS: Immediate breast reconstruction after mastectomy for breast cancer does not lead to an increased incidence of wound complications nor delay the initiation of systemic chemotherapy. DESIGN AND SETTING: Retrospective medical record review at a tertiary care center. PATIENTS: One hundred twenty-eight women treated with a mastectomy for breast cancer over an 8-year period (January 1, 1995, through December 31, 2002). MAIN OUTCOME MEASURES: Surgical site complications (infectious and noninfectious) and time to initiation of postoperative chemotherapy. RESULTS: One hundred forty-eight mastectomy procedures in 128 women with breast cancer were evaluated. We analyzed 4 subgroups according to whether or not immediate breast reconstruction was part of the surgical procedure (76 or 72 procedures, respectively) and whether or not postoperative adjuvant chemotherapy was administered (81 or 47 patients, respectively). There was an increased incidence of wound complications in patients who underwent immediate breast reconstruction compared with those who did not (6/72 [8.3%] vs 17/76 [22.3%]; P = .02). However, these complications did not delay initiation of postoperative chemotherapy. CONCLUSIONS: Although we observed an increased incidence of wound complications when immediate breast reconstruction was combined with mastectomy, there was no delay in the initiation of adjuvant therapy. Immediate breast reconstruction should remain an important treatment option after mastectomy even when postoperative chemotherapy is anticipated.

Hilar cholangiocarcinoma: surgical and endoscopic approaches.

HCCa remains an uncommon malignancy, though increasing use of more radical surgery has led to prolonged survival in those patients who undergo curative resection. The extent of these resections suggest that the best results are likely to be obtained in centers with the resources and experience to conduct these operations in a safe fashion. Until major advances in the systemic therapy of HCCa are made, however, the management should focus on optimal preoperative imaging and palliation of jaundice with improvement in quality of life.

Women surgeons in the new millennium.

BACKGROUND: Women are increasingly entering the surgical profession. OBJECTIVE: To assess professional and personal/family life situations, perceptions, and challenges for women vs men surgeons. DESIGN: National survey of American Board of Surgery-certified surgeons. PARTICIPANTS: A questionnaire was mailed to all women and men surgeons who were board certified in 1988, 1992, 1996, 2000, or 2004. Of 3507 surgeons, 895 (25.5%) responded. Among these, 178 (20.3%) were women and 698 (79.7%) were men. RESULTS: Most women and men surgeons would choose their profession again (women, 82.5%; men, 77.5%; P = .15). On multivariate analysis, men surgeons (odds ratio [OR], 2.5) and surgeons of a younger generation (certified in 2000 or 2004; OR, 1.3) were less likely to favor part-time work opportunities for surgeons. Most of the surgeons were married (75.6% of women vs 91.7% of men, P < .001). On multivariate analysis, women surgeons (OR, 5.0) and surgeons of a younger generation (OR, 1.9) were less likely to have children. More women than men surgeons had their first child later in life, while already in surgical practice (62.4% vs 32.0%, P < .001). The spouse was the offspring's primary caretaker for 26.9% of women surgeons vs 79.4% of men surgeons (P < .001). More women surgeons than men surgeons thought that maternity leave was important (67.8% vs 30.8%, P < .001) and that child care should be available at work (86.5% vs 69.7%, P < .001). CONCLUSIONS: Women considering a surgical career should be aware that most women surgeons would choose their profession again. Strategies to maximize recruitment and retention of women surgeons should include serious consideration of alternative work schedules and optimization of maternity leave and child care opportunities.

Career and lifestyle satisfaction among surgeons: what really matters? The National Lifestyles in Surgery Today Survey.

BACKGROUND: Optimizing recruitment of the next surgical generation is paramount. Unfortunately, many nonsurgeons perceive surgeons' lifestyle as undesirable. It is unknown, however, whether the surgeons-important opinion makers about their profession-are indeed dissatisfied. STUDY DESIGN: We analyzed responses to a survey mailed to all surgeons who were certified by the American Board of Surgery in 1988, 1992, 1996, 2000, and 2004. We performed multivariate analyses to study career dissatisfaction and inability to achieve work-life balance, while adjusting for practice characteristics, demographics, and satisfaction with reimbursement. RESULTS: A total of 895 (25.5%) surgeons responded: mean age was 46 years; 80% were men; 88% were married; 86% had children; 45% were general surgeons; 72% were in urban practice; and 83% were in nonuniversity practice. Surgeons worked 64 hours per week; ideally, they would prefer to work 50 hours per week (median). Fifteen percent were dissatisfied with their careers. On multivariate analysis, significant (p < 0.05) risk factors were nonuniversity practice (odds ratio [OR] 3.3) and dissatisfaction with reimbursement (OR 5.9). Forty percent would not recommend a surgical career to their own children. On multivariate analysis, significant risk factors were nonuniversity practice (OR 2.5) and dissatisfaction with reimbursement (OR 3.4). In all, 33.5% did not achieve work-life balance. On multivariate analysis, dissatisfaction with reimbursement (OR 3.0) was a significant risk factor. Respondents' lives could be improved by "limiting emergency call" (77%), "diminishing litigation" (92%), and "improving reimbursement" (94%). CONCLUSIONS: Most surgeons are satisfied with their careers. Areas in need of improvement, particularly for nonuniversity surgeons, include reimbursement, work hours, and litigation. Strong local and national advocacy may not only improve career satisfaction, but could also render the profession more attractive for those contemplating a surgical career.

Racial and ethnic differences in treatment and survival among adults with primary extremity soft-tissue sarcoma.

BACKGROUND: Limb preservation is preferred to amputation for patients with extremity soft tissue sarcoma (ESTS). Disparities in the treatment and outcomes of several malignancies have been reported, but not for ESTS. The authors assessed racial/ethnic differences in patient- and tumor-specific characteristics, treatment, and disease-specific survival in a population of adults with ESTS. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 6406 adult patients with ESTS who were diagnosed and treated between 1988 and 2003. Patients were categorized into 1 of 4 racial/ethnic groups: whites, blacks, Hispanics, and Asians. Comparisons of treatment and disease-specific survival were conducted with regression models that adjusted for patient age, sex, SEER geographic region, extent of disease, tumor grade, tumor size, and histology. RESULTS: Relative to whites, blacks received lower rates of adjuvant radiation with surgery (odds ratio [OR], 0.77; 95% confidence interval [95% CI], 0.66-0.90). Hispanics received significantly lower rates of limb-sparing surgery (OR, 0.76; 95% CI, 0.59-0.97). In a multivariate analysis controlling for patient age, sex, SEER geographic region, extent of disease, tumor grade, tumor size, and histology, blacks displayed a worse disease-specific survival (hazard ratio [HR] 1.39; 95% CI, 1.13-1.70), whereas Asians demonstrated superior disease-specific survival (HR, 0.67; 95% CI, 0.46-0.97). CONCLUSIONS: There were significant racial/ethnic differences in treatment and survival among adults with ESTS. Compared with whites, survival was poorer for blacks but better for Asians. These disparities were not explained by differences in patient or tumor characteristics.

Upstaging and improved survival of early breast cancer patients after implementation of sentinel node biopsy for axillary staging.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has become a standard for axillary staging for early breast cancer patients. Prior studies suggest that SLNB may be more sensitive for the identification of lymph node disease than axillary lymph node dissection (ALND). We hypothesized that SLNB use increases the incidence of node-positivity in early breast cancer patients compared to ALND. Furthermore, survival improves due to more accurate staging (stage migration). METHODS: Registry data from an NCI-designated cancer center was reviewed for breast cancer patients with T1 and T2 tumors for two 5-year periods: before (1993-1997) and after (2000-2004) SLNB implementation (1998). TNM staging was updated to conform to American Joint Committee on Cancer (AJCC) 2003 guidelines. RESULTS: There were no differences in tumor size or stage groupings between the two time periods (n = 316 and 577). There was a non-significant increase in the proportion of patients with lymph node involvement (32 vs. 27%; P = .16) after SLNB implementation; though a trend of increased incidence of single-node positive patients was observed (13 vs. 8%; P = .07). This was significant in patients with T1A/T1B tumors (10 vs. 3%; P = .04), though not seen in T1C or T2 tumors. Stage II survival improved in the later time period (P = .02). CONCLUSIONS: The increase in single-node positivity after SLNB implementation supports the theory that SLNB is more sensitive than ALND. Improvements in survival are likely due to the stage migration of patients who would have been node-negative by ALND (but were found to be node-positive by SLNB) in addition to improvements in adjuvant therapy.

Tumors of the retrorectal space.

PURPOSE: Retrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential. METHODS: The incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis. RESULTS: Retrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions. CONCLUSIONS: Retrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Controlled tamponade of severe presacral venous hemorrhage: use of a breast implant sizer.

Hemorrhage from the presacral venous plexus is a potentially life-threatening complication of pelvic operations. The morbidity and mortality that stems from severe hemorrhage has led to the development of various hemostatic techniques. Although suture ligature, packing, and placement of tacks can be very effective, they can often be unsuccessful. When these conventional hemostatic techniques fail, alternative approaches are required. We describe the successful use of an expandable breast implant sizer and outline the practical, theoretical, and financial advantages of applying this technique when more conservative approaches have failed.

Multimodality management of a giant cell tumor arising in the proximal sacrum: case report.

STUDY DESIGN: Descriptive. OBJECTIVE: To outline a novel multimodality approach for a difficult surgical resection of a giant cell tumor in the cephalad portion of the sacrum. SUMMARY OF BACKGROUND DATA: Giant cell tumors of the sacrum are rare primary bone tumors. Recent reports have demonstrated diminished giant cell tumor recurrence with cryosurgery by using a "direct pour" technique with liquid nitrogen. Although successful in decreasing tumor recurrence, this technique is accompanied by a 4%-8% rate of skin necrosis and high rates of pathologic fracture. The authors describe resection and a novel, controlled method of argon-based cryotherapy (followed by a unique pelvic reconstruction) for a large, difficult giant cell tumor of the sacrum. METHODS: A 29-year-old woman presented with complaints of right foot drop and decreased sensation of the right buttock, posterior thigh, posterior calf, and lateral aspect of the right foot. Radiographic evaluation revealed a mass in the right sacrum; histologic examination of CT-guided biopsy revealed a giant cell tumor. A combined anterior abdominal and posterior sacral approach was performed, the tumor was resected, and the margin of the cavity was treated with controlled argon-based cryotherapy. The combination of thermocouples, electromyographic monitoring, and rapid freeze-thaw cycles allowed a controlled ablation of the tumor margin while ensuring that surrounding structures, such as the rectal wall, sacral nerves, and gluteal muscles, were not damaged. Posterior spinal fusion L4 to sacrum, posterior spinal instrumentation L4 to pelvis, and allograft reconstruction of the right sacrum were performed. RESULTS: The patient recovered well without skin necrosis or pathologic fracture. Urinary and fecal continence were preserved. At the 20-month follow-up the patient has no evidence of local tumor recurrence and is fully ambulatory without a brace or narcotic medication. CONCLUSION: A novel multimodality approach, consisting of resection, controlled cryosurgery, and a unique lumbopelvic reconstruction, was safe and successful in managing a challenging proximal sacral giant cell tumor. Twenty months after surgery the patient has excellent bowel and bladder control, no tumor recurrence, and functional ambulation without a brace or pain.

Dermatofibrosarcoma protuberans: reappraisal of wide local excision and impact of inadequate initial treatment.

BACKGROUND: The extent of local invasion in dermatofibrosarcoma protuberans (DFSP) is often clinically difficult to appreciate, and this leads to inadequate resections. We examined the effect of inadequate initial treatment and the efficacy of wide resection. METHODS: We performed a retrospective analysis of the records of 35 patients with DFSP treated at our institution (1985 and 2001). Data were analyzed with Wilcoxon's ranked sum test and Fisher's exact test. RESULTS: Of the 24 patients eligible for analysis, 11 had definitive wide resection after diagnostic excisions elsewhere (primary group), and 13 had recurrent tumors after previous surgical treatment elsewhere (recurrent group). Twenty-three patients were treated with wide resection only, and adjuvant radiation was administered to one patient who had a fibrosarcoma. At a median follow-up of 54 months, patients definitively treated at our institution had a 100% local recurrence-free survival. In comparison to the primary group, recurrent DFSPs were significantly larger and deeper and occurred in the head and neck region. Five cases had bone involvement, and of these, 80% occurred in the recurrent group. CONCLUSIONS: Inadequate initial treatment results in larger, deeper recurrent lesions, but these can be managed by appropriate wide excision. Wide resection of DFSP (whether recurrent or primary) with negative histological margins predicts a superior local recurrence-free survival.