Identification and Management of Abdominal Aortic Dissection With Concurrent Aneurysm.

The incidence of acute aortic dissection ranges from 2.6 to 3.5 per 100,000 people per year. An abdominal aortic dissection is known to be the rarest of all types of aortic dissection, with high morbidity and mortality rates. In this case report, we are hoping to shed light on this unusual entity, its etiology, and management options.

Open Cholecystectomy for the New Learner-Obstacles and Challenges.

BACKGROUND: Laparoscopy has become the standard of care in most general surgery procedures. This has led to a decrease in the number of open surgical procedures for surgical training, particularly as senior surgeons retire. The aim of this study was to evaluate the impact of retiring senior surgeons on our residents' operative experience. METHODS: Cholecystectomies performed between Jan 2010 and Dec 2016 were retrospectively reviewed. Surgeons training residents were divided into two groups based on their training experience. Group 1 were trained in the prelaparoscopic era, and group 2 were trained during the age of laparoscopy. We then evaluated the impact of retirement on the number of open cholecystectomies performed. RESULTS: There were 4555 laparoscopic cholecystectomies performed at our institution over a 7-year period. Overall conversion rate was 1.5% (66/4555). Conversion rates were higher in group 1 as compared to group 2. The analysis of the number of open cases performed by each graduating resident showed reduction in the number of open cholecystectomies performed over time. CONCLUSION: The decline in the number of open cholecystectomies creates a challenge for the training of general surgery residents. To compensate, we have employed simulation curriculum with the use of cadaveric surgical anatomy courses. Additionally, with transplant curriculum, open cholecystectomy experience has increased with liver transplant exposure. Continued laparoscopic experience has also shown that advanced laparoscopic techniques such as top down dissection laparoscopically have decreased the need for conversion to open and are skills that graduating residents possess.

Outcome of African-American compared to White-American patients with early-stage breast cancer, stratified by phenotype.

BACKGROUND: Breast cancer mortality rates are 39% higher in the African-American (AA) women compared to White-American (WA) women despite the advances in overall breast cancer screening and treatments. Several studies have undertaken to identify the factors leading to this disparity in United States with possible effects of lower socioeconomic status and underlying aggressive biology. METHODS: A retrospective analysis was done using a prospectively maintained database of a metropolitan health system. Patients were selected based on diagnosis of early-stage breast cancer between 10/1998 and 02/2017, and included women over age of 18 with clinically node-negative disease. Patients were then stratified by phenotype confirmed by pathology and patient-identified race. RESULTS: A total of 2,298 women were identified in the cohort with 39% AA and 61% WA women. The overall mean age at the time of diagnosis for AA women was slightly younger at 60 years compared to 62 years for WA women (p = 0.003). Follow-up time was longer for the WA women at 95 months vs. 86 months in AA women. The overall 5-year survival was analyzed for the entire cohort, with the lowest survival occurring in patients with triple-negative breast cancer (TNBC). Phenotype distribution revealed a higher incidence of TNBC in AA women compared to WA women (AA 16% vs. WA 10%; p < 0.0001). AA women also had higher incidence of HER2 positive cancers (AA 16.8% vs. WA 15.3%; p < 0.0001). WA women had a significantly higher distribution of Non-TNBC/HER2-negative phenotype (AA 55% vs. WA 65%; p < 0.0001). Furthermore, a subgroup analysis was done for a sentinel lymph node (SLN) negative cohort that showed higher rates of grade 3 tumors in AA (AA 35% vs. WA 23%; p < 0.0001); and higher rates of grade 1 and grade 2 tumors in WA (30% vs. 21% and 44% vs. 40%). Despite higher grade tumors in AA women, five-year overall survival outcomes in SLN-negative cohort did not differ between AA and WA women when stratifying based on tumor subtype. CONCLUSION: Breast cancer survival disparities in AA and WA women with SLN-negative breast cancer are diminished when evaluated at early-stage cancers defined by SLN-negative tumors. Our evaluation suggests that when diagnosed early, phenotype does not contribute to racial survival outcomes. The lower survival rate in AA women with breast cancer may be attributed to later stage biology between the two races, or underlying socioeconomic disparities.

Clinicopathological and Perioperative Outcome of Appendiceal Tumors: Case Review of 31 Patients.

INTRODUCTION: Neoplasms of the appendix are quite rare and found in approximately 1% of appendectomy specimens. These neoplasms have been pathologically categorized into various subgroups depending on cell of origin, and surgical treatment varies according to histological subtype and disease stage. PURPOSE: The purpose of this case series review was to evaluate the clinicopathological presentation and survival outcome of a sample of patients with appendiceal tumors. METHODS: Before data collection, this project design was approved by the authors' institutional review board. Pathology records at our institution were reviewed for cases of appendiceal tumors from January 2007 to December 2016. A total of 31 patients were identified over this 10-year period. Retrospective data collection included patient demographics, presenting symptoms, tumor size, histologic diagnosis, initial and secondary management, perioperative and postoperative outcome, and survival benefits. RESULTS: Thirty one patients with four different appendiceal tumor subtypes were included in the study: Mucinous Cystadenoma, Mucinous Adenocarcinoma, Goblet Cell, and Carcinoid. The sample was comprised of 17 women (54.8%) and 14 men (45.2%) with an overall mean age of 50.1 (SD = 22.3). Subgroups of 13 (42%) patients had Carcinoid tumor, 12 (39%) had Mucinous Cystadenoma, four (13%) had Goblet cell tumor, and two (6%) had Mucinous Adenocarcinoma. The stage at presentation and tumor size also varied by histologic subtype. The most common presenting symptom was abdominal pain (64.5%), followed by a radiological identified mass (12.9%). Overall, 27 (87.1%) patients survived, and four (12.9%) were deceased. CONCLUSIONS: The findings from this case series review provides a retrospective analysis of appendiceal tumor characteristics, follow up, and survival. Based on these results, the prognosis and management of patients with these tumors should be based on the histologic subtype and the extent of their disease.

Relationship between BI-RADS and the Results of the Wire-Guided Percutaneous Localization for Non-Palpable Breast Lesions.

INTRODUCTION: The aim of this study is to evaluate the relationship between Breast Imaging Reporting and Data System and surgical biopsies that may increase effectiveness of wire-guided percutaneous localizations for non-palpable breast lesions. METHODS: A retrospective review of a sample of 149 patients who underwent wire-guided localization with wide local excision for non-palpable breast lesions at the authors' institution between January 2013 and April 2016. After IRB approval, sample patients' records were reviewed and data were collected concerning their radiological, histological and surgical characteristics. RESULTS: One (0.67%) complication occurred related to wire migration. There were nine (6.04%) recorded cases of seroma and three (2.01%) cases of hematoma. Breast Imaging Reporting and Data System (BI-RADS) Category 4 was found to have a positive predictive value of 28.4% for breast cancer. Under Category 4 subcategorization 4A, 4B, and 4C, the number of positive lesions were two (6.89%), three (10.34%) and five (17.24%), respectively. Forty (78.43%) of the 51 patients with cancer had negative (i.e., non-cancerous) margins compared to 11 (21.57%) cases that had positive margins after the first procedure. CONCLUSION: The BI-RADS Category 4 encompasses the majority of lesions, with approximately 70% of such biopsies lesions later found to be benign. A subcategorization of BI-RADS 4 needs further clarification in distinguishing benign vs malignant imaging characteristics. Future retrospective studies designed to identify benign vs. malignant lesions, confirmed by validating prospective studies, will better clarify a new subcategorization of BI-RADS Category 4, thus allowing surgeons and radiologists to make the best surgical recommendations for their patients.

Single-site robotic cholecystectomy: comparison of clinical outcome and the learning curves in relation to surgeon experience in a community teaching hospital.

BACKGROUND: The aim of this study was to analyze the experience of two surgeons who have different laparoscopic skills and case volume, with single-site robotic cholecystectomy (SSRC) and evaluate their learning curves. METHODS: All SSRCs performed between March 2013 and April 2015 were retrospectively reviewed. The patients were divided among two surgeons based on the surgeon's level of laparoscopic skills and case volume. Surgeon 1 had experience in advanced laparoscopy while surgeon 2 had basic laparoscopic skills. Patients' demographic data, intraoperative and short-term postoperative results were assessed. RESULTS: The analysis included 102 patients for surgeon 1 and 15 patients for surgeon 2. There were no major or minor complications in either cohort. Operative time was significantly longer for surgeon 2, conversion to laparoscopy rate was 4% for surgeon 1 compared to 20% for surgeon 2, P = 0.044, which is statistically significant. CONCLUSIONS: SSRC is an easy and safe procedure that can be quickly learned and performed in a reproducible manner by surgeons with experienced laparoscopic skills and greater case volume.

Tension pneumoperitoneum after bystander cardiopulmonary resuscitation: A case report.

INTRODUCTION: Abdominal visceral injuries after cardiopulmonary resuscitation (CPR) are infrequent though can be significant complications of CPR requiring invasive interventions. We present a case of a gastric perforation as a result of bystander CPR. This resulted in tension pneumoperitoneum necessitating abdominal decompression prior to laparotomy and repair. PRESENTATION OF CASE: 37-year-old female complained of abdominal pain and distension after return of spontaneous circulation from successful CPR following a drug overdose and cardiopulmonary arrest. Abdominal imaging showed significant amounts of free intraperitoneal air causing compression of the abdominal visceral organs. Patient underwent exploratory laparotomy. Prior to induction of general anesthesia with potential cardiovascular collapse from the tension pneumoperitoneum, the abdomen was decompressed with a spring-loaded insufflation (Veress) needle while the patient was awake. Upon exploration, there were two three-centimeter gastric perforations that were primarily repaired with omental patch. The patient had an uneventful recovery and discharged home on postoperative day four. CONCLUSION: The Veress needle, usually used for insufflating the abdomen during laparoscopy, can also be an effective tool to decompress the abdomen when presented with tension pneumoperitoneum. Abdominal visceral injuries are rare following CPR but do occur and will likely require an invasive intervention. Surviving cardiac arrest as a young person and living without deficits outweighs the risk of a surgical correction for a visceral injury. While resuscitation measures are critical for survival, medical personnel need to be aware of potential complications from resuscitative efforts and potential management strategies.

Synchronous perforation of non-Hodgkin's lymphoma of the small intestine and colon: a case report.

INTRODUCTION: Primary non-Hodgkin's lymphoma of the small and large bowel presenting as a perforated viscus entity with peritonitis is extremely rare. A thorough literature review did not reveal any cases where primary lymphoma of the jejunum presented with perforation and peritonitis synchronously with primary lymphoma of the descending colon. CASE PRESENTATION: This report concerns a 64-year-old Caucasian woman admitted with severe abdominal pain and fever. An emergency laparotomy revealed a large mass with perforation in the proximal jejunum with intense mesenteric thickening and lymphadenopathy. The descending colon was edematous and covered with fibrinous exudate. Histopathological examination of the resected segment of jejunum revealed a T cell non-Hodgkin's lymphoma. On post-operative day 10, a computed tomography scan of our patient's abdomen and pelvis showed leakage of contrast into the pelvis. Re-exploration revealed perforation of the descending colon. The histopathology of the resected colon also showed T cell non-Hodgkin's lymphoma. Her post-operative course was complicated by acute renal and respiratory failure. The patient died on post-operative day 21. CONCLUSIONS: Lymphoma of the small intestine has been reported to have a poor prognosis. The synchronous occurrence of lesions in the small intestine or colon is unusual, and impacts the prognosis adversely. Early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkin's lymphoma.