Seeding recurrence of follicular thyroid carcinoma after transoral endoscopic thyroidectomy vestibular approach: a case report.

Background: While track recurrence of thyroid cancer following endoscopic and robotic transaxillary surgeries has been reported previously, no such cases have been reported for transoral endoscopic thyroidectomy vestibular approach (TOETVA). This case report describes the first documented case of recurrence of thyroid cancer along the surgical track after TOETVA. Case Description: The patient underwent right lobectomy via TOETVA for a 4 cm follicular thyroid carcinoma (FTC) initially diagnosed as benign follicular nodule on preoperative gun biopsy. The thyroid capsule partially ruptured within the surgical field during surgery. Ultrasonography and computed tomography conducted 27 months after surgery revealed seeding recurrence in the postsurgical thyroid bed, and subcutaneous layers of the right lower lip, submental area, and mid to right upper neck levels I, IIA, and VI. Two-stage re-operation was done to perform completion thyroidectomy, lymph node dissection, and excision of recurrent nodules, which were pathologically confirmed as metastatic FTC. The patient underwent two treatments of radioactive iodine therapy, and post-therapeutic whole-body scintigraphy and computed tomography showed no residual disease. Conclusions: Careful monitoring after TOETVA is essential due to the rare but potential risk of seeding recurrence, especially when the thyroid gland ruptures during surgery. Surgeons should be aware of this atypical complication and be prepared to recommend surgical and/or medical strategies to manage any local seeding of thyroid tissue that may occur.

Re-do transoral robotic thyroidectomy is feasible: preliminary results of the surgical feasibility and efficacy of completion transoral robotic thyroidectomy: cohort study.

BACKGROUND: Transoral robotic thyroidectomy (TORT) has proven to be a safe and effective procedure with favourable surgical and cosmetic outcomes, but its application in completion thyroidectomy procedures remains to be established. In this study, the authors present our experience with completion TORT, assessing its surgical feasibility and efficacy. between February 2017 and August 2023. METHODS: The authors conducted a retrospective analysis of consecutive patients who underwent completion TORT after an initial TORT procedure between February 2017 and August 2023. RESULTS: A total of 10 patients (three males and seven females) were included in the study, with a mean age of 42.2±13.5 years. The indications for completion thyroidectomy included five cases of aggressive initial lesions and five cases of metachronous papillary thyroid carcinoma detected in the remnant lobe. The median interval between the initial and completion TORT procedures was 6.5 months. Flap dissection time showed no significant difference between the initial TORT and completion TORT operations (43.3±7.5 vs. 36.2±11.2, P =0.125). However, the mean console time (127.9±42.6 vs. 86.4±26.3 min, P =0.019) and mean total operation time (206.7±65.9 vs. 146.0±34.9 min, P =0.021) were significantly longer during the initial TORT procedure than during the completion TORT procedure. Two patients experienced transient hypoparathyroidism, which resolved within four weeks postoperatively. No other complications, such as vocal cord palsy, mental nerve injury, or bleeding, were observed. The median follow-up period was 21.5 months, and no recurrences were detected in any of the patients. CONCLUSIONS: Our study demonstrates that re-do TORT is feasible, showing excellent cosmetic results and minimal adverse effects. Completion TORT may be considered a viable option for selected patients who require completion thyroidectomy after an initial TORT procedure.

Transoral endoscopic thyroidectomy vestibular approach vs. transoral robotic thyroidectomy: systematic review and meta-analysis.

This study aimed to conduct a systematic review and meta-analysis to compare the surgical outcomes of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT). We carried out a systematic literature search of PubMed, Web of Science, Cochrane Library, and Google Scholar on studies comparing TOETVA and TORT until January 2023. A total of five articles published between 2018 and 2023 that matched the inclusion criteria were included in the systematic review and meta-analysis. The studies included 641 patients (394 TOETVA patients and 247 TORT patients). TOETVA group was associated with a significantly shorter operative time with a mean difference of 60.08 min [95% confidence interval (CI) - 83.95 to - 36.20; P < 0.001). Transient recurrent laryngeal nerve palsy was more common in the TOETVA group than the TORT group (OR 3.00; 95% CI 1.14-7.88; P = 0.03). There were no significant differences in the other outcomes, including the length of hospital stay, postoperative pain scores, number of central lymph nodes retrieved, permanent recurrent laryngeal nerve injuries, and transient and permanent hypoparathyroidism. The TOETVA group was associated with shorter operative time and more transient recurrent laryngeal nerve palsy than the TORT group. Each procedure has its benefits and limitations. The surgical approach should be determined by considering the patient's characteristics and preferences, as well as the surgeon's preference and area of expertise.

Transoral endoscopic thyroidectomy vestibular approach as a safe and feasible alternative to open thyroidectomy: a systematic review and meta-analysis.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a scarless alternative to open thyroidectomy (OT). This systematic review and meta-analysis aimed to synthesize evidence comparing the intraoperative and postoperative outcomes of TOETVA and OT. METHODS: A systematic literature search of PubMed, Web of Science, the Cochrane Library, and Google Scholar was performed to identify studies comparing the outcomes of TOETVA and OT published before February 2023. The outcomes of interest were operative time, intraoperative blood loss, hospital stay, postoperative pain, number of central lymph nodes retrieved, number of metastatic central lymph nodes, and incidences of transient and permanent recurrent laryngeal nerve injury, transient and permanent hypocalcemia, hematoma, and infection. RESULTS: Thirteen studies published between 2016 and 2022, involving a total of 2889 patients (TOETVA, n =1085; OT, n =1804) were included in this systematic review and meta-analysis. Meta-analysis showed that the TOETVA group had a significantly longer overall operative time (weighted mean difference [WMD] 55.19; 95% CI, 39.15, 71.23; P <0.001), longer hospital stay (WMD, 0.27; 95% CI, 0.14, 0.39; P <0.001), and lower pain scores on postoperative day 1 (WMD, -1.41; 95% CI, -2.79, -0.03; P =0.04) than the OT group. Other intraoperative and postoperative outcomes were not significantly different between the groups. CONCLUSION: TOETVA has a similar safety profile to OT with less postoperative pain, making it an appropriate and more cosmetically appealing alternative to OT for select patients.

The fate of donor-type ABO blood group antigen expression in liver grafts in ABO-incompatible adult living donor liver transplantation.

BACKGROUND/PURPOSE: Donor-type ABO blood group antigens (dABOAgs) have been detected in ABO-incompatible adult living donor liver transplantation (ABOi ALDLT) grafts, but their fate and role in ABOi ALDLT rejection remain uncertain. METHODS: The 0-day, <1-month, and 1-year serial liver graft biopsies from 30 ABOi ALDLT recipients were retrospectively evaluated. ABO antigen expression was quantitatively and serially measured by the mean number of positively stained vascular structures (endothelium of the capillaries, arteries, hepatic veins, and portal veins) within the portal tracts (sS). RESULTS: The dABOAg sS counts of 0-day, <1-month, and 1-year liver graft biopsies (32.3, 20.8, and 20.6, respectively) decreased significantly (p < .001). Early rejection in the <1-month biopsy was observed in 8/30 (26.7%) recipients, four (13.3%) of whom showed antibody-mediated rejection. The sS counts tended to rebound in grafts showing early rejection, with minimal changes from the 0-day to <1-month period, but increased to pre-transplantation levels after 1 year, compared to that in grafts without early rejection (36.0, 20.4, 19.6 vs. 23.7, 21.9, 23.0, respectively; p = .040). CONCLUSIONS: While dABOAg expression decreased after ABOi ALDLT, recipients showing early rejection showed sustained graft dABOAg expression. Therefore, dABOAg expression may be involved in the mechanism of accommodation in ABOi transplantation.

Comparative surgical outcomes of transoral endoscopic and robotic thyroidectomy for thyroid carcinoma: a propensity score-matched analysis.

BACKGROUND: Surgical outcomes of patients with thyroid carcinoma who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) versus transoral robotic thyroidectomy (TORT) were compared. METHODS: Patients who underwent TOETVA or TORT between July 2016 and February 2022 were retrospectively analyzed. TOETVA and TORT groups were propensity score-matched (1:1) based on age, sex, body mass index, surgical extent, tumor size, and presence of thyroiditis. RESULTS: A total of 185 patients underwent transoral thyroidectomy (142 TOETVA and 43 TORT). Final diagnoses consisted of 135 papillary and seven follicular thyroid carcinomas in the TOETVA group and 43 papillary thyroid carcinomas in the TORT group (p = 0.138). Mean operative time was shorter for the TOETVA group than the TORT group (106.3 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer for the TOETVA group than the TORT group (2.2 vs. 1.9 days, p = 0.031). After 1:1 propensity score matching, each group included 43 patients. Mean operative time was shorter in the TOETVA group than the TORT group (106.2 vs. 158.9 min, p < 0.001), whereas mean hospital stay was longer in the TOETVA group (2.3 vs. 1.9 days, p = 0.031). There was no significant difference in vocal cord palsy incidences between the groups (one transient, one permanent in the TOETVA group vs. none in the TORT group, p = 0.359). The learning curve was 71 cases for TOETVA and 25 cases for TORT. CONCLUSION: TOETVA had shorter mean operative time, and TORT had shorter learning curve and shorter mean hospital stay. Surgeons should be familiar with the advantages and disadvantages of each procedure.

Standardized Intraoperative Neuromonitoring Procedure is Feasible in Transoral Endoscopic Thyroidectomy.

BACKGROUND: Intraoperative neuromonitoring in thyroid surgeries has become popular, but the standardized manner of intraoperative neuromonitoring during transoral endoscopic thyroidectomy vestibular approach (TOETVA) is not well established. This study evaluated the feasibility of using a standardized intraoperative neuromonitoring method for TOETVA. METHODS: Medical records of consecutive patients who underwent TOETVA with intraoperative neuromonitoring were retrospectively reviewed. Patients were positioned before intubation to prevent tube migration, then intubated using video laryngoscopy. The electromyography amplitudes of the vagal nerves and the recurrent laryngeal nerves were checked before (V1, R1) and after (V2, R2) thyroid resection. V1 and V2 signals were evaluated using a long ball tip stimulator with a stimulus current of 3 mA. R1 and R2 signals were obtained using the stimulus current of 1 to 3 mA. RESULTS: Forty-two patients (3 males and 39 females) were included. Lobectomy was performed in 40 patients (95.2%) and total thyroidectomy in 2 (4.8%). Pathologic diagnoses were 30 papillary thyroid carcinomas, 2 follicular thyroid carcinomas, and 9 benign diseases. Conversion to open surgery occurred in 1 patient due to bleeding. Thus, 43 nerves at risk in 41 patients were analyzed. V1 and R1 signals were detected from all nerves. The mean V1 and R1 amplitudes were 738.7±391.4 µV and 804.4±347.5 µV, respectively, and 38 (88.3%) and 39 (90.7%) nerves had R1 and V1 amplitudes of more than 500 µV. There were 2 cases (4.6%) of transient recurrent laryngeal nerve injury. R2 and V2 signals were detected in the 41 remaining nerves. The mean R2 and V2 amplitudes were 917.2±505.2 µV and 715.7±356.2 µV, respectively, and 36 (87.8%) and 32 (78.0%) nerves had respective R2 and V2 amplitudes of more than 500 µV. CONCLUSIONS: Intraoperative neuromonitoring could be performed in a standardized manner in TOETVA, and the quality of intraoperative neuromonitoring was excellent. Further studies are needed to verify the feasibility of the current approach.

Administration of neostigmine after tracheal intubation shortens time to successful intraoperative neuromonitoring during thyroid surgery: a randomized controlled trial.

This prospective, randomized controlled trial evaluated the effect of neostigmine for intraoperative neuromonitoring (IONM) during thyroid surgery. Forty subjects undergoing thyroidectomy with IONM, randomized into neostigmine administration after tracheal intubation (Group N, n = 20) or control treatment with normal saline (Group C, n = 20), completed the trial. Electromyography amplitudes of the vagus nerve (V1) were recorded before thyroid dissection. The time from the initial V1 signal check to successful V1 stimulation was recorded. In Group N, all the patients had a successful V1 signal at the first check, whereas ten (50%) patients in Group C had a time delay between the initial V1 check and successful V1 (p < 0.001). The mean delay time among the delayed patients in Group C was 11.2 ± 1.4 min. The mean time from skin incision to successful V1 stimulation was significantly shorter in Group N than in Group C (15.4 ± 2.4 min vs. 19.9 ± 5.7 min, p = 0.003). In Groups N and C, the mean V1 amplitudes were 962.2 ± 434.5 µV vs. 802.3 ± 382.7 µV (p = 0.225), respectively, and the mean R1 amplitudes were 1240.0 ± 836.5 µV vs. 1023.4 ± 455.8 µV (p = 0.316), respectively. There was one bucking event in Group N. In conclusion, neostigmine administration immediately after tracheal intubation can be useful to reverse neuromuscular blockade for successful IONM in thyroid surgeries.

Investigation of the clinical features and recurrence patterns of acute right-sided colonic diverticulitis: A retrospective cohort study.

Background: Right-sided colonic diverticulitis (RCD) and left-sided colonic diverticulitis (LCD) are considered distinct diseases. However, separate guidelines for RCD do not exist. Since the establishment of RCD management would first require evaluation of disease characteristics and recurrence patterns, this study has aimed to investigate the differences in the clinical characteristics between RCD and LCD and the recurrence patterns of RCD. Methods: Patients admitted for colonic diverticulitis between January 2012 and August 2020 were retrospectively reviewed. Clinical characteristics and recurrence rates in RCD and LCD patients, and predictors for recurrence and the recurrence patterns of RCD were analyzed. Results: In total, 446 colonic diverticulitis patients (343 RCD, 103 LCD) were included in this study. RCD patients were more likely to be male, younger, taller, heavier, smoke, drink alcohol, have better physical performance scores, lower modified Hinchey stages and better initial laboratory findings. LCD patients were more likely to receive invasive treatments, have longer fasting and hospital days, higher mortality and cumulative recurrence rates (20.5% vs. 30.4%, P = 0.007). Recurrences in most RCD patients were of similar disease severity and received the same treatments for initial attacks, with rates of recurrence increasing after each recurrence. Predictors of the recurrence of RCD were complicated diverticulitis (hazard ratio[HR] 2.512, 95% confidence interval[CI] 0.127-5.599, p = 0.024) and percutaneous drainage (HR 6.549, 95% CI 1.535-27.930, p = 0.011). Conclusion: RCD is less severe and has a lower recurrence rate than LCD, suggesting that RCD should be treated conservatively. Patients with complicated diseases and those requiring percutaneous drainage are more likely to experience a disease recurrence, suggesting nonsurgical management may be insufficient.

Long-Term Oncologic Outcomes for T2 Gallbladder Cancer According to the Type of Surgery Performed and the Optimal Timing for Sequential Extended Cholecystectomy.

BACKGROUND: Sequential extended cholecystectomy (SEC) is currently recommended for T2 and higher gallbladder cancer (GBC) diagnosed after simple cholecystectomy (SC), but the value and timing of re-resection has not been fully studied. We evaluated the long-term oncologic outcomes of T2 GBC according to the type of surgery performed and investigated the optimal timing for SEC. METHODS: Patients diagnosed with T2 GBC who underwent SC, extended cholecystectomy (EC), or SEC between 2002 and 2017 were retrospectively reviewed. Those who underwent other surgical procedures or those with incomplete medical records were excluded. Overall survival (OS) and disease-free survival (DFS) according to the types of surgeries and prognostic factors for OS and DFS were analyzed. Survival analysis was done between groups that were divided according to the optimal cutoff time interval between SC and SEC based on DFS data. RESULTS: Of the 226 T2 GBC patients, 53, 173, and 44 underwent SC, EC, and SEC, respectively. The 5-year OS rate was 50.1%, 73.2%, and 78.7%, and the DFS rate was 46.8%, 66.3%, and 65.2% in the SC, EC, and SEC groups, respectively. EC (p = 0.001 and p = 0.001) and SEC (p = 0.007 and p = 0.065) groups had better 5-year OS and DFS rates than the SC group. Preoperative CA 19-9 level > 37 U/mL (HR 1.56; 95% CI 1.87-2.79; p < 0.001) and N1 stage (HR 2.88; 95% CI 1.76-4.71; p < 0.001) were associated with poorer prognosis. The optimal cutoff interval between SC and SEC was 28 days. Patients who underwent SEC ≤ 28 days after the initial cholecystectomy had better 5-year DFS rates than patients who underwent SEC after > 28 days (75.0% vs. 52.8%, p = 0.023). CONCLUSIONS: SEC is recommended for T2 GBC diagnosed after SC, because SEC provides better survival outcomes than SC alone. A time interval of less than 28 days to SEC is associated with an improved DFS.

Investigation of potential neuropharmacological activity of neostigmine-glycopyrrolate for intraoperative neural monitoring in thyroid surgery.

Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve injury. The use of neuromuscular blockade agent to facilitate tracheal intubation, is a common cause of IONM failure. We performed a retrospective analysis to assess the efficacy of neostigmine-glycopyrrolate as a neuromuscular blockade reversal agent for IONM during thyroid surgery. Rocuronium (0.6 mg/kg) was administered for muscle relaxation. Neostigmine (2 mg) and glycopyrrolate (0.4 mg) were administered immediately after intubation. Cricothyroid muscle-twitch response upon external branch of superior laryngeal nerve stimulation and electromyography amplitudes of vagal and recurrent laryngeal nerves before (V1, R1) and after thyroid resection (V2, R2) were recorded. Fifty patients (23 males, 27 females) were included in the analysis. The diagnoses comprised 43 papillary thyroid carcinomas and seven benign diseases. The mean time between rocuronium injection and neostigmine-glycopyrrolate injection was 5.1 ± 1.2 min, and the mean time from neostigmine-glycopyrrolate injection to successful cricothyroid muscle twitching upon external branch of superior laryngeal nerve stimulation was 21.0 ± 4.5 min. All patients had V1 and R1 amplitudes of more than 500 µV each, with mean V1 and R1 amplitudes of 985.3 ± 471.6 µV and 1177.2 ± 572.7 µV, respectively. Neostigmine-glycopyrrolate was effectively used as a neuromuscular blockade reversal agent for IONM in thyroid surgeries without a significant increase in bucking events. Administration of neostigmine-glycopyrrolate immediately after intubation can be recommended for successful NMB reversal to facilitate IONM during thyroid surgery.

Application of patch stimulator for intraoperative neuromonitoring during thyroid surgery: maximizing surgeon's convenience.

BACKGROUND: Intraoperative neuromonitoring (IONM) is frequently used in thyroid surgery to reduce recurrent laryngeal nerve (RLN) injury by providing the surgeon with real-time feedback on nerve stimulation during dissection. We applied a disposable adhesive patch electrode to a dissecting instrument to transfer electrical stimulation to the dissecting instrument for IONM during thyroid surgery. This study aimed to evaluate the feasibility of using the patch stimulator approach for IONM during thyroid surgery. METHODS: We reviewed the medical records of patients who underwent thyroidectomy using both conventional stimulator and adhesive patch stimulator for IONM. The electromyography (EMG) amplitudes of the vagal and the RLNs before (V1, R1) and after thyroid resection (V2, R2) were alternatively checked with each type of stimulator at the same location of each nerve. RESULTS: Fifteen consecutive patients (4 males, 11 females) were included in this analysis, and a total of 38 nerves (19 vagus nerves and 19 RLNs) were evaluated. No statistically significant differences were seen in the mean amplitudes evoked by the patch stimulator and the conventional probe stimulator for the V1 signal (825.5±394.6 vs. 821.8±360.9 µV, P=0.954), R1 signal (1,044.8±471.2 vs. 1,039.2±507.4 µV, P=0.898), R2 signal (1,037.8±495.0 vs. 938.2±415.8 µV, P=0.948), or V2 signal (812.5±391.9 vs. 787.3±355.7 µV, P=0.975). CONCLUSIONS: The patch stimulator was safely and effectively used for IONM during thyroid surgery and provided similar nerve monitoring responses as the conventional stimulator. This approach may be used to enhance the surgeon's convenience during thyroid surgery.

Conversion surgery for initially unresectable extrahepatic biliary tract cancer.

BACKGROUNDS/AIMS: Surgical resection is the only curative treatment for biliary tract cancers; however, most patients undergo palliative chemotherapy because they are contraindicated for surgery. Conversion surgery, a treatment strategy for downsizing chemotherapy and subsequent surgical resection, is feasible for initially unresectable biliary tract cancers following the introduction of effective chemotherapeutic agents. METHODS: Patients initially diagnosed with unresectable biliary tract cancers, and treated with conversion surgery after palliative chemotherapy between 2013 and 2019, were reviewed retrospectively. RESULTS: Twelve patients underwent conversion surgery after palliative chemotherapy for initially unresectable biliary tract cancers. The final pathological diagnosis included six perihilar cholangiocarcinomas, four distal common bile duct cancers, and two gallbladder cancers. Different chemotherapy regimens were used, but all the patients were treated with gemcitabine at some point during their treatment. The median overall survival was 28 months, which was longer than that of patients treated with isolated palliative chemotherapy in previous studies. CONCLUSIONS: Conversion surgery represents a therapeutic alternative for specific cases of unresectable biliary tract cancers. Palliative chemotherapy for initially unresectable biliary tract cancers is recommended for downsizing the tumor and expanding the indications for surgery. Further studies and clinical trials are required to develop new and effective chemotherapeutic regimens.

Changes in postoperative long-term nutritional status and quality of life after total pancreatectomy.

PURPOSE: Quality of life (QoL) is widely known to be poor after total pancreatectomy (TP) due to the loss of pancreatic function and poor nutritional status, but prospective studies on changes in QoL over time are lacking. The aim of this study was to prospectively evaluate the short- and long-term consequences of pancreatic exocrine insufficiency, changes in nutritional status, and their associated effects on QoL after TP. METHODS: Prospective data were collected from patients who underwent TP between 2008 and 2018. Validated questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] Core 30, EORTC QLQ-pancreatic cancer module, and the Mini Nutritional Assessment), measured frequency of bowel movement, relative body weight (RBW), triceps skinfold thickness (TSFT), and serum levels of protein, albumin, transferrin, and hemoglobin A1c were collected serially for 1 year. RESULTS: Thirty patients who underwent TP were eligible for the study. Bowel movement frequency increased over time, and the RBW and TSFT were lowest by 1 year. The global health status score showed no significant difference over time. At 3 months, physical and role function scores as well as symptoms of fatigue, constipation, and digestive difficulties worsened significantly. Most indices recovered after 1 year, but poorer physical function scores, digestive difficulties, and altered bowel habits persisted. CONCLUSION: Because some symptoms do not recover over time, careful follow-up and supportive postoperative management are needed for TP patients, including nutritional support with pancreatic enzyme replacement and education about medication adherence and diet.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): Surgical Outcomes and Learning Curve.

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) has excellent cosmetic effects and its popularity is increasing worldwide. We present our experience with TOETVA and its short-term outcomes. This study included 110 consecutive patients who underwent TOETVA at a single institution between July 2016 and June 2020. We analyzed clinicopathologic data, short-term postoperative outcomes, and learning curve using cumulative summation (CUSUM) analysis. Of the 110 patients who underwent TOETVA, 101 had malignant disease and 100 (90.9%) underwent lobectomy. The mean age was 39.7 ± 9.7 years, and the mean tumor size was 1.0 ± 0.7 cm (range, 0.3-3.6 cm). Operation time was 168.0 ± 63.4 min for total thyroidectomy, 111.0 ± 27.7 min for lobectomy, and 73.7 ± 18.1 min for isthmusectomy. Five patients (4.5%) experienced transient vocal cord palsy (VCP) and one (0.9%) had permanent VCP. The swallowing impairment index-6 score was 2.18 ± 3.21 at postoperative three months, and 0.97 ± 1.72 at postoperative six months. The learning curve for lobectomy was 58 cases in CUSUM analysis. TOETVA is a safe and feasible approach with an acceptable operation time and a low complication rate. This approach is a surgical option for patients who desire excellent cosmesis.

Comparison of Long-Term Oncological Outcomes in Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery for Breast Cancer: A Propensity Score-Matched Analysis.

PURPOSE: The oncoplastic breast-conserving surgery (OPS) technique, combined with the principles of oncological safety and plastic surgery, results in complete tumor resection while preserving the natural appearance of the breast. The purpose of this study was to evaluate the long-term oncological results after OPS compared with conventional breast-conserving surgery (BCS) for early breast cancer. METHODS: The medical records of patients who underwent breast cancer surgery and adjuvant radiation therapy at Seoul National University Hospital between 2011 and 2014 were reviewed. Ipsilateral breast tumor recurrence (IBTR)-free survival rate and recurrence-free survival (RFS) rates were compared between the OPS and BCS groups. RESULTS: One-to-one propensity score matching was conducted, yielding 371 patients in each group. The mean tumor distance from the nipple was shorter, and the mean retrieved specimen size and pathologic tumor size, including ductal carcinoma in situ, were larger in the OPS group than in the conventional BCS group (p < 0.001). Surgical margin positivity was not significantly different between the two groups (p = 0.777). The surgical technique was not significantly associated with IBTR (OPS versus conventional BCS, 5-year survival rate, 96.9% vs. 98.6%; p = 0.355) and RFS (5-year survival rate, 92.9% vs. 94.5%; p = 0.357) on the log-rank test. Multivariate analysis revealed that OPS versus conventional BCS was not significantly associated with survival outcomes. CONCLUSION: We observed no significant differences in long-term IBTR and RFS between the OPS and conventional BCS groups in this retrospective analysis. OPS can be an oncologically and surgically safe alternative option for conventional BCS for early breast cancer.

Natural history and optimal treatment strategy of intraductal papillary mucinous neoplasm of the pancreas: Analysis using a nomogram and Markov decision model.

BACKGROUND/PURPOSE: With the increase in detection of intraductal papillary mucinous neoplasms (IPMN), a tailored approach is needed. This study was aimed at exploring the natural history of IPMN and suggest optimal treatment based on malignancy risk using a nomogram and Markov decision model. METHODS: Patients with IPMN who underwent surveillance or surgery were included. Changes in worrisome features/high-risk stigmata and malignancy conversion rate were assessed. Life expectancy and quality-adjusted life year (QALY) were compared using a nomogram predicting malignancy. RESULTS: Overall, 2006 patients with histologically confirmed or radiologically typical IPMN were enrolled. Of these, 1773 (88.4%), 81 (4.0%), and 152 (7.6%), respectively, had branch duct (BD)-, main duct-, and mixed-type IPMN at initial diagnosis. The cumulative risk of developing worrisome feature or high-risk stigmata was 19.0% and 35.0% at 5- and 10-year follow-up, respectively. The progression of malignancy rate at 10-year follow-up was 79.9% for main and mixed IPMNs and 5.9% for BD-IPMN. Nomogram-based malignancy risk prediction is well correlated with natural history based on pathologic biopsy and shows good stratification of survival. The decision model recommends surgery to maximize survival and QALY especially in those with >35% malignancy risk. CONCLUSIONS: Compared with main duct- and mixed-type IPMN, which have a high risk of malignancy (79.9%), BD-IPMN is very indolent (5.9%). The nomogram-based decision model suggests surgery rather than surveillance for patients with a high malignancy risk. The optimal treatment strategy between surgery and surveillance should consider patients' health status, malignancy risk, and centers' experience.

Standard or Variant Meso-Rex Shunts for Children with Variceal Bleeding due to Extrahepatic Portal Vein Obstruction: A Report of Two Cases.

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of pediatric portal hypertension and can cause life-threatening variceal bleeding. Meso- Rex shunt (MRS) is a surgical procedure that restores physiological portal venous blood flow to the liver by using a graft to connect the superior mesenteric vein and the left portal vein within the Rex recess, and can relieve variceal bleeding and other complications associated with EHPVO. Although the MRS is regarded as an optimal and potentially curative treatment with good long-term patency, graft thrombosis or failure due to unknown causes is not rare, prompting the need for further research on the risk factors of graft failure or poor patency. Herein, we report two cases of EHPVO in patients with recurrent or uncontrolled variceal bleeding, one treated with the classic Rex shunt and the other with the modified Rex shunt, which resulted in a failure and success, respectively.

Omega-3 and -6 Fatty Acid Intake and Colorectal Cancer Risk in Swedish Women's Lifestyle and Health Cohort.

PURPOSE: We aimed to assess the association between the dietary intake of fish-derived omega-3 polyunsaturated fatty acids and the risk of colorectal cancer among Swedish women. MATERIALS AND METHODS: A total of 48,233 women with information on dietary intake were included in the analysis. Participants were followed for incident colorectal cancer until 31 December 2012. Cox proportional hazard models were used to assess the association between baseline fatty acid intake and colorectal cancer risk. All analyses were stratified by colon and rectal cancers. RESULTS: During a median of 21.3 years of follow-up, a total of 344 colorectal cancer cases were ascertained. Although there was no overall association between omega-3 fatty acid intake and colorectal cancer risk, high intake of fish-derived docosahexaenoic acid was associated with reduced risk of rectal cancer (hazard ratios for the third and the highest quartiles were 0.59 (95% confidence interval [CI], 0.37 to 0.96) and 0.62 (95% CI, 0.39 to 0.98), respectively). CONCLUSION: In conclusion, we found only limited support for an association between omega-3 polyunsaturated fatty acids and colorectal cancer in a large Swedish cohort of middle-aged women.