Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to-Inframammary Fold Measurement.

BACKGROUND: The authors refine their anatomical patient selection criteria with a novel midclavicular-to-inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach. METHODS: Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained. RESULTS: One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch-to-nipple distance, was strongly correlated with midclavicular-to-inframammary fold measurement on linear regression (R = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to-inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to-inframammary fold measurement was less than 30 cm. CONCLUSIONS: Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to-inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to-inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A ruptured recurrent small bowel gastrointestinal stromal tumour causing hemoperitoneum.

Hemoperitoneum is a rare and potentially life-threatening complication of GIST. We reported a 54-year-old man who developed disseminated intra-abdominal recurrence from a previously resected gastrointestinal stromal tumour (GIST) of the small bowel, and the patient presented with hemoperitoneum. Emergent debulking surgery was performed. A high dose imatinib was prescribed. Despite the presence of residual disease, the patient was well clinically 8 months after the operation. Even though, there is no evidence to support the routine use of debulking surgery in the management of GIST. In our patient, disease progression after second line targeted therapy and the absence of alternative treatment options for spontaneous rupture and hemoperitoneum prompted us to treat the patient aggressively. Resection of the ruptured GIST was carried out for control of bleeding and to prevent recurrent bleeding in this patient with good surgical risks. During the treatment decision-making, the patient's general condition, the risk of surgery and the extent of dissemination were taken into consideration. In this patient who presented with spontaneous rupture of a small intestinal GIST, the novel use of targeted therapy and aggressive surgical treatment produced reasonably good survival outcome.

The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: a comprehensive review.

BACKGROUND: Surgery on patients with malignant obstructive jaundice carries increased risks of postoperative morbidity and mortality. Preoperative biliary drainage has been developed to reduce this procedure-related risks, but its role in patients who are going to receive pancreaticoduodenectomy for periampullary carcinoma is still controversial. METHODS: This article aimed at reviewing the current status of preoperative biliary drainage for patients with peri-ampullary tumors who were candidates for pancreaticoduodenectomy. A MEDLINE and PubMed database search from 1980 to 2013 was performed to identify relevant articles using the keywords "pancreaticoduodenectomy", "preoperative biliary drainage", "jaundice", "peri-ampullary neoplasm" and "carcinoma of pancreas". Additional papers were identified by a manual search of the references from the key articles. RESULTS: There were six randomized controlled trials (RCTs) and 5 meta-analyses on preoperative biliary drainage for patients with malignant obstructive jaundice. Most of the results of these studies could not be used to define the role of preoperative biliary drainage for patients who received pancreaticoduodenectomy for periampullary carcinoma because: first, the majority of these studies were on bypass or palliative resections; second, various pathologies with both proximal and distal biliary obstruction were included; third, there were different forms of percutaneous or endoscopic drainage procedures; fourth, there were different durations of preoperative drainage; and finally, there were variations in the definition of events and outcomes. There was only one RCT which included a homogeneous group of patients with carcinoma of pancreas who underwent pancreaticoduodenectomy. For patients with periampullary tumor, the RCTS and meta-analyses showed no benefit of preoperative biliary drainage. Instead, there were some concerns about the drainage-related complications and the increase in positive intraoperative bile culture rate and the associated infective complication rate postoperatively. CONCLUSION: Routine preoperative biliary drainage showed no beneficial effect on the surgical outcome for patients with periampullary tumor. A selective approach of preoperative biliary drainage should be adopted for these patients. The optimal duration and modality of preoperative biliary drainage remain unclear.

Current management of gastrointestinal stromal tumors--a comprehensive review.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) comprise < 1% of all gastrointestinal (GI) tumors, but GISTs are the most common mesenchymal tumors of the GI tract. Dramatic changes in clinical practice have been observed in the last decade. This review highlights the overall management of GIST and its recent developments. METHOD: We identified literature by searching Medline and PubMed from January 1995 to December 2011 using the keywords "gastrointestinal stromal tumors", "GIST", "imatinib" and "tyrosine kinase inhibitor". Additional papers were identified by a manual search of the references from the key articles. There were no exclusion criteria for published information to the topics. RESULTS: For localized primary GISTs, surgical resection is the mainstay of therapy. The 5-year survival rate after complete resection of GISTs is approximately 50%-65%. Many factors including tumor size, mitotic rate, tumor location, kinase mutational status and occurrence of tumor rupture have been extensively studied and proposed to be predictors of survival outcomes. Adjuvant imatinib is proposed as an option for those patients with a substantial risk of relapse. Unresectable metastatic or recurrent GIST can be treated with a tyrosine kinase inhibitor, imatinib, with a remarkable response (50%-70%) and prolonged survival (median progression-free survival: 18-20 months; median overall survival: 51-57 months). The standard approach in the case of tumor progression on 400 mg once per day is to increase the imatinib dose to 400 mg twice per day as permitted by toxicity. Use of a second-line targeted agent, sunitinib, in patients with advanced GIST who fail (or are intolerant of) imatinib therapy is advised. CONCLUSION: Treatment for GISTs has become increasingly complex because of the growing understanding of its biology. A multidisciplinary team that includes radiologists, medical oncologists, pathologists, and surgeons is paramount for the effective treatment of GIST.

Methods of vascular control technique during liver resection: a comprehensive review.

BACKGROUND: Significant hemorrhage together with blood transfusion increases postoperative morbidity and mortality of hepatic resection. Hepatic vascular occlusion is effective in minimizing bleeding during hepatic parenchymal transection. This article aimed to review the current role and status of various techniques of hepatic vascular occlusion during hepatic resection. DATA SOURCES: The relevant manuscripts were identified by searching MEDLINE, and PubMed for articles published between January 1980 and April 2010 using the keywords "vascular control", "vascular clamping", "vascular exclusion" and "hepatectomy". Additional papers were identified by a manual search of the references from the key articles. RESULTS: One randomized controlled trial (RCT) and 5 RCTs showed intermittent Pringle maneuver and ischemic preconditioning followed by continuous Pringle maneuver were superior to continuous Pringle maneuver alone, respectively. Two RCTs compared the outcomes of hepatectomy with and without intermittent Pringle maneuver. One showed Pringle maneuver to be beneficial, while the other failed to show any benefit. One RCT showed that ischemic preconditioning had significantly less blood loss than using intermittent Pringle maneuver. Four RCTs evaluated the use of hemihepatic vascular occlusion. One RCT showed it had significantly less blood loss than Pringle maneuver, while the other 3 showed no significant difference. Only 1 RCT showed it had significantly less liver ischemic injury. No RCT had been carried out to assess segmental vascular occlusion. Two RCTs compared the outcomes of total hepatic vascular exclusion (THVE) and Pringle maneuver. One RCT showed THVE resulted in similar blood loss, but a higher postoperative complication. The other RCT showed less blood loss using THVE but the postoperative complication rate was similar. Both studies showed similar degree of liver ischemic injury. Only one RCT showed that selective hepatic vascular exclusion (SHVE) had less blood loss and liver ischemic injury than Pringle maneuver. CONCLUSION: Due to the great variations in these studies, it is difficult to draw a definitive conclusion on the best technique of hepatic vascular control.

Management of bile duct injury after laparoscopic cholecystectomy: a review.

BACKGROUND: Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy. METHODS: Medline and PubMed database search was undertaken to identify articles in English from 1970 to 2008 using the key words 'bile duct injury', 'cholecystectomy' and 'classification'. Additional papers were identified by a manual search of the references from the key articles. Case report was excluded. RESULTS: Early recognition of bile duct injury is of paramount importance. Only 25%-32.4% of injuries are recognized during operation. The majority of patients present initially with non-specific symptoms. Management depends on the timing of recognition, the type, extent and level of the injury. Immediate recognition and repair are associated with improved outcome, and the minimum standard of care after recognition of bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. There is a growing body of literature supporting the importance of early referral to a tertiary care hospital which can provide a multidisciplinary approach to treat bile duct injury. Inadequate management may lead to severe complications. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. The optimal management depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons.

Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review.

OBJECTIVE: To review the current evidence on the efficacy of various interventions directed toward prevention of pancreatic fistula after pancreatoduodenectomy. DATA SOURCES: A MEDLINE database search from January 1, 1990, to August 31, 2008, was performed to identify relevant articles using the keywords pancreatoduodenectomy, pancreaticojejunostomy, pancreaticogastrostomy, pancreatic anastomotic leakage, and pancreatic fistula. Additional articles were identified by a manual search of the references from the key articles. STUDY SELECTION: Case reports were excluded from this study. DATA EXTRACTION: Of the identified studies, only those published in English describing meta-analyses or randomized controlled trials were considered first. In those aspects with limited or no randomized controlled trials, nonrandomized comparative studies and case series were included also. DATA SYNTHESIS: The prophylactic use of perioperative somatostatin and its analogues to prevent pancreas-related complications after pancreatic surgery remains controversial and does not result in a reduction of operative mortality. There is no clear evidence for or against a particular type of pancreaticoenteric anastomosis. Pancreaticoenterostomy cannot be replaced by pancreatic ductal obliteration. Pancreaticogastrostomy is equivalent to pancreaticojejunostomy in perioperative morbidity and mortality. CONCLUSION: More large-scale comparative studies and randomized controlled trials are required to determine the optimum pharmacologic interventions and technique of pancreaticoenteric anastomosis after pancreatoduodenectomy.

The current role of neoadjuvant/adjuvant/chemoprevention therapy in partial hepatectomy for hepatocellular carcinoma: a systematic review.

BACKGROUND: Following curative treatment for hepatocellular carcinoma (HCC), 50%-90% of postoperative death is due to recurrent disease. Intra-hepatic recurrence is frequently the only site of recurrence. Thus, any neoadjuvant or adjuvant therapy, which can decrease or delay the incidence of intra-hepatic recurrence, or any cancer chemoprevention which can prevent a new HCC from developing in the liver remnant, will improve the results of liver resection. This article systematically reviewed the current evidence of neoadjuvant, adjuvant, and chemoprevention in partial hepatectomy of HCC. DATA SOURCES: Studies were identified by searching MEDLINE and PubMed databases for articles from January 1990 to November 2008 using the keywords "hepatocellular carcinoma", "hepatectomy", "adjuvant therapy", "neoadjuvant therapy", and "regional therapy". Additional papers and book chapters were identified by a manual search of the references from the key articles. RESULTS: Neoadjuvant transarterial chemoembolization or adjuvant regional transarterial chemotherapy+/- embolization+systemic chemotherapy did not add benefit. Both adjuvant transarterial radioembolization with 131I-lipiodol and adjuvant systemic interferon showed promising results. However, there were only a limited number of such studies. CONCLUSIONS: Further randomized controlled studies need to be carried out. Currently, there is no consensus on a standard neoadjuvant/adjuvant/chemoprevention therapy in partial hepatectomy for HCC.