Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass.

BACKGROUND: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss. METHODS: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN). RESULTS: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group. CONCLUSIONS: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.