Complication Rates After Intraoperative Radiation Therapy: Do Applicator Size and Distance to Skin Matter?

BACKGROUND: Intraoperative radiation therapy (IORT) has gained popularity for early stage breast cancer treatment. Few studies have examined the relationship between complications and both demographic and technical factors. The objective of the current study was to determine if applicator size or distances to the skin were significant risk factors for complications. METHODS: Data was prospectively collected on patients who underwent lumpectomy followed by IORT from November 1, 2013 to August 31, 2018. Exclusion criteria included any prior radiation exposure or personal history of breast cancer. Comorbid conditions such as body mass index, diabetes, and smoking as well as technical specifications such as applicator size and distances to the skin were included for investigation. Student's t-test, Fisher's exact test, and odds ratios were utilized for statistical analysis. RESULTS: The study was comprised of 219 patients. None developed Clavien-Dindo grade 2 or above complications. Of 21.0% (n = 46) had minor complications. The most common complication was a palpable breast seroma (n = 37). Diabetes was the only comorbid condition with increased risk for complications (OR 3.2; 95% CI1.3-7.5; P = 0.008). The applicator sizes and average skin distances were similar between groups. Surprisingly, the closest skin distance was not a significant risk factor for post-operative complications (1.4 +/- 1.6 versus 1.4 +/- 1.9 cm; P = 1.0). CONCLUSION: Neither applicator size nor the closest skin distance were associated with increased complications. Traditionally described risk factors such as BMI and smoking were not predictive. This data provides support for potentially expanding the utilization for IORT without increasing complications.

Recurrent Intestinal Obstruction after Radiation Therapy: A Case Report and Review of the Literature.

INTRODUCTION: In patients who have undergone resection for rectal cancer after neoadjuvant radiotherapy, loop ileostomy is commonly performed with few serious complications. In rare cases, if this irradiated small bowel is strictured, reversal of the affected ileostomy can have dire consequences. We present a case of a 62-year-old male with recurrent intestinal obstruction after closure of his loop ileostomy. CASE REPORT: RC is a 62-year-old male who initially presented with rectal cancer and underwent neoadjuvant chemoradiation prior to a laparoscopic low anterior resection with diverting loop ileostomy. He underwent elective reversal of his ileostomy and developed persistent postoperative obstruction. He underwent resection of the prior reversal site with normal-appearing dilated proximal bowel loops and collapsed distal bowel loops. He again developed an obstructive picture and underwent resection of the prior anastomosis with creation of an ileocolic anastomosis, after which he recovered well postoperatively. CONCLUSION: In patients who receive radiation adjuvant therapy for colon cancer, radiation-induced stricture should be considered as a cause of small bowel obstruction postoperative. In the setting of a longstanding ileostomy, evaluation of a defunctionalized distal ileum may be necessary to evaluate potential obstruction from radiation changes.

A different type of perforation: appendicitis after colonoscopy.

Physicians who perform colonoscopy should consider appendicitis in the differential diagnosis of post procedure abdominal pain. Diagnostic laparoscopy is a safe adjunct for evaluation in patients with suspected perforation after colonoscopy. It is important that all physicians be aware of this complication to ensure prompt diagnosis and intervention.

Intestinal obstruction caused by desmoid tumours: a review of the literature.

Intraabdominal desmoid tumours are rare and can cause intestinal obstruction. Based on the review of the literature, surgical resection with negative margins and adjuvant chemotherapy is the optimal strategy for treatment of this pathology.

Demographics and socioeconomic status as predictors of weight loss after laparoscopic sleeve gastrectomy: A prospective cohort study.

BACKGROUND: Prior studies have established that race and socioeconomic factors may influence weight loss after bariatric surgery. Few studies have focused on laparoscopic sleeve gastrectomy (LSG). The objective of this study is to determine if demographic factors may predict postoperative weight loss following LSG. METHODS: Prospectively collected data on 713 consecutive primary LSG operations performed with the same technique between February 2010 and May 2016 by a single surgeon (PG) were analyzed. Multiple regression analysis was done to determine if gender, race, or socioeconomic factors such as insurance and employment status correlated with postoperative weight loss. The presence of chronic comorbidities affecting quality of life such as Type II Diabetes and Obstructive Sleep Apnea (OSA) were also recorded and analyzed. RESULTS: All studied groups had similar preoperative body mass index (BMI) (mean 46 kg/m2). Race was not significantly associated with weight loss at any postoperative interval. Male gender was associated with increased weight loss through the first three months (48.2 ±â€¯12.5 lbs vs. 40.5 ±â€¯11 lbs; p = 0.0001). Patients with diabetes had significantly less weight loss at the 6 through 18 month intervals (50.4 ±â€¯17.9 lbs vs. 59.6 ±â€¯15.6 lbs at six months; p = 0.00032; 53.3 ±â€¯25.4lbs vs. 80.5 ±â€¯31.3lbs at 18 months; p = 0.008). Patients with obstructive sleep apnea had significantly less weight loss at the two-year interval (57.5 ±â€¯29.2 lbs) vs. those without obstructive sleep apnea (69.6 ±â€¯23.5 lbs; p = 0.047). Those with Medicare compared to Medicaid or commercial insurance had decreased weight loss through the first year (52.8 ±â€¯20.8 lbs vs. 71.4 ±â€¯26.4 lbs vs. 68.6 ±â€¯24.7 lbs; p = 0.0496). Notably, a higher percentage of patients in the Medicare insurance group were also diabetic and had OSA (65% vs. 34% vs. 36%; p = 0.002; 80% vs. 55% vs. 57%; p = 0.01). Finally, those patients who were students had the greatest weight loss at two years postoperatively with the least weight loss seen in retired patients followed by those on disability (108.0 ±â€¯21.5 lbs vs. 26.0 lbs vs. 46.0 ±â€¯19.7 lbs; p = 0.04). CONCLUSIONS: Several demographic factors including comorbidities, insurance status, and employment may significantly affect weight loss patterns following LSG. Further studies are needed to evaluate whether demographic differences impact long term weight loss. Differences in outcomes based on patient demographics may be beneficial in the planning of the allocation of healthcare resources.

Distracting injury defined: does an isolated hip fracture constitute a distracting injury for clearance of the cervical spine?

OBJECTIVES: As the population within the USA ages, the number of hip fractures seen yearly in the emergency department is expected to rise. According to the NEXUS criteria, many of these patients receive computerized tomographic scan (CT) evaluation of the cervical spine because a hip fracture may constitute a distracting injury. The objective of this study is to determine if an isolated hip fracture constitutes a distracting injury which requires imaging of the cervical spine. METHODS: Data were prospectively collected on 158 trauma patients with isolated hip fractures between April 1, 2015 and March 9, 2016. Patient demographics were analyzed and compared to the National Emergency X-Radiography Utilization Study (NEXUS). RESULTS: Patients with isolated hip fractures were predominantly elderly, on average 78.6 +/- 15.9 years old, and 94.3% of these injuries occurred after a fall from standing. Only one patient also had a cervical spine fracture which was not clinically significant. When compared to the established rate of cervical spine injury of 2.4%, the absolute risk reduction (ARR) was 0.35% (95% CI, - 1.06 to 1.75%) and the number needed to treat (NNT) was 290. CONCLUSION: In the case of an elderly patient with an isolated hip fracture and no cervical midline tenderness, cervical spine imaging may be reserved for those who have other NEXUS criteria for further workup.

Over the hill and falling down: Can the NEXUS criteria be applied to the elderly?

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) criteria have been criticized due to the presumed unreliability of the clinical exam in elderly patients. The objective of this study was to determine if the NEXUS criteria can be safely applied to this vulnerable group of patients. METHODS: 596 trauma patients over the age of 65 were enrolled in a prospectively designed study between April 1, 2015 and October 1, 2016. The study was designed to encourage the use of the NEXUS criteria for all trauma patients including the elderly. NEXUS-negative patients (n = 226) were defined as individuals fulfilling none of the low risk criteria. The specificity and sensitivity of the NEXUS criteria were calculated based on any cervical spine injuries which were missed in NEXUS-positive patients (n = 129) who met one or more criteria. RESULTS: Out of the 596 included elderly patients, 355 patients underwent computed tomography (CT) of the cervical spine. 129 patients were NEXUS-positive and in this group ten nonoperative cervical spine injuries were detected. There were no NEXUS-positive patients who did not undergo CT scans of the cervical spine. No cervical spine injuries were detected in the 226 NEXUS-negative patients. In elderly patients, the NEXUS criteria had a sensitivity of 100% and specificity of 100%. CONCLUSION: The NEXUS criteria have been criticized in prior literature as less sensitive in elderly patients. Based on the current study, the use of the NEXUS criteria may lead to decreased radiation exposure and healthcare costs allowing for better allocation of resources for patients who warrant imaging of the cervical spine.

Robotic repair of a right-sided Bochdalek hernia: a case report and literature review.

BACKGROUND: Bochdalek hernias (BHs) are usually diagnosed in the neonatal period, occurring in 1/2200-1/12,500 live births. There are few reported cases of BHs in adults. Robotic repair has not been described in current literature as opposed to the laparoscopic approach. Here we present a case of an adult with clinical signs of bowel obstruction secondary to a BH which was repaired using a robotic approach. CASE REPORT: A 74-year-old gentleman with past medical history of benign prostatic hyperplasia presented to the emergency department with a 1-week history of nausea, vomiting, diarrhea, and decline in appetite. Computed tomography (CT) imaging of the chest and abdomen revealed elevation of the right hemidiaphragm and evidence of small bowel obstruction. The patient was managed conservatively with nasogastric tube placement and bowel rest. He underwent colonoscopy which could not be completed secondary to a transverse colon stricture which was confirmed by barium enema. Upon repeat CT imaging, the patient was found to have herniated colon through a right-sided diaphragmatic hernia which caused colonic narrowing. The patient's intestinal obstruction improved clinically with continued conservative management and he underwent robotic repair of a right posterior diaphragmatic hernia. The hernia defect was closed with interrupted figure of eight Ethibond sutures. A right-sided chest tube was placed. Intraoperatively, the herniated proximal transverse colon was noted to be ischemic and a right hemicolectomy was performed. He recovered well and was discharged home on postoperative day 5. CONCLUSION: Congenital diaphragmatic hernias usually present in the neonatal period and are rare in adults. Operative repair is recommended and laparoscopic repair has been described. Based on the existing literature regarding laparoscopic repair and the current case report, robotic repair also appears to be a viable and safe option.

Glomangiosarcoma Arising from a Prior Biopsy Site.

Glomangiosarcoma represents a rare malignant variant of the benign glomus tumor that typically presents as a tender, slowly growing nodule with a predilection for the lower extremities. Unlike their benign counterparts, glomangiosarcomas may display aggressive characteristics such as large size, local invasion, and a tendency to recur after excision. Although wide local excision remains the treatment of choice, rare cases of systemic metastasis have been previously reported. We present a case of glomangiosarcoma arising at a prior biopsy site after excision of an unknown soft tissue lesion.

Readmission Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND OBJECTIVES: Prior studies have established a 1.7-4.33% readmission rate for laparoscopic sleeve gastrectomy (LSG), a rate that falls within the reported range for other bariatric procedures. The current report describes the incidence of 30-day readmission after primary LSG procedures performed at a single bariatric center of excellence (COE) and examines factors that may be associated with readmission. METHODS: Data on 343 consecutive LSG operations performed from February 2010 to May 2014 by a single surgeon (PG) were analyzed. Patients readmitted within 30 d were compared to the remaining patients by using Student's t test for continuous variables and the χ2 test for categorical variables. RESULTS: All LSGs were completed laparoscopically with no conversions to open procedures. There were no reoperations, leaks, perioperative hemorrhages, or mortalities. Twelve patients (3.5%) were readmitted; 1 was readmitted twice. There were no identified risk factors for readmission, including patient demographics, comorbidities, and perioperative factors. Notably, 7 (7%) readmissions occurred in the initial 100 patients and 5 (2%) in the remaining 243 patients (P = .04). Clinical pathways were modified after the initial 100 patients; routine contrast esophagograms were no longer performed, and a 1-day routine postoperative stay was adopted. Operative time also decreased from 94.2 ± 23.8 to 78.2 ± 20.0 min (P < .001). CONCLUSIONS: Readmission rates after LSG remain in a range similar to those described for other laparoscopic bariatric procedures. Larger prospective studies are needed to identify patterns of complications and readmissions in patients undergoing LSG that may differ from other bariatric procedures.