Rate of re-excision after breast-conserving surgery for invasive lobular carcinoma.

Invasive lobular carcinoma (ILC) accounts for approximately 5 to 20 per cent of all breast cancers and is often multicentric. Despite pre- and intraoperative assessments to achieve negative margins, ILC is reported to be associated with higher rates of positive margin. This cross-sectional study examined patients with breast cancer treated at our institution from 2000 to 2010. The objective was to investigate the rate of re-excision resulting from positive or close margin (1 mm or less) in patients who underwent breast-conserving surgery (BCS) for ILC compared with invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). Of the 836 patients treated, 416 patients underwent BCS. The rate of re-excision after BCS for ILC was 35.1 versus 17.7 per cent for IDC and 20.0 per cent for DCIS (P = 0.04). Re-excisions were more often performed for positive margin in patients with ILC (11 of 37 [29.7%]) versus IDC (36 of 334 [10.8%]) and DCIS (five of 45 [11.1%];(P = 0.004). In this single-institution review, BCS for ILC had significantly higher rates of re-excision as a result of positive margins when compared with IDC and DCIS. Tumor size greater than 2 cm and lymph node involvement were identified as factors associated with positive surgical margin in ILC. The higher possibility of positive margins and the need for additional procedures should be discussed with patients undergoing BCS for ILC.

Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost.

BACKGROUND: The acute care surgery model is a novel notion in the provision of emergency general surgery. To date, several studies have analyzed the effects on patient health outcomes and timeliness of care for nontrauma patients within the scope of acute general surgery and emergencies, but none have assessed the cost benefits of this model. STUDY DESIGN: A retrospective analysis of patients undergoing appendectomy or cholecystectomy in the setting of acute abdomen was performed to compare data from 2 cohorts, the traditional model from July 2009 to June 2010 and the acute care surgery model from July 2010 to June 2011. Categorical variables and comparison means were examined using chi-square and independent 2-tailed sample t-tests. RESULTS: One hundred and seventy-five patients underwent appendectomy and 113 underwent cholecystectomy. The traditional model team staffed 82 appendectomies and 51 cholecystectomies, and the acute care surgery team staffed 93 and 62, respectively. In the appendectomy group, there was a statistically significant mean reduction of time to surgical evaluation (2.19 hours; p < 0.001) and time to the operating room (5.38 hours, p = 0.006), there were 7 fewer patients with complications (p = 0.06) and a reduced length of stay (1 day, p = 0.002) for the acute care surgery cohort. Similar statistically significant differences were observed in the cholecystectomy group in the acute care surgery cohort: surgical evaluation difference = 5.84 hours (p = 0.03), time to operating room difference = 25.37 hours (p = 0.002), 8 fewer patients with complications (p = 0.01), and length of stay difference was 2 days (p = 0.03) compared with the traditional model cohort. CONCLUSIONS: The newly implemented acute care surgery model in our institution accomplished earlier treatment and shorter length of stay for the 2 most common causes of acute abdomen in our setting. Overall, the new model translated to better outcomes for patients and savings per case for the hospital.