Bilateral accessory axillary breast tissue in a premenarchal female.

A 9-year-old premenarchal female presented to pediatric dermatology with a 6-month history of periodically tender, bilateral and symmetric axillary masses. Magnetic resonance imaging and subsequent surgical excision confirmed the diagnosis of bilateral accessory axillary breast tissue. Accessory axillary breast tissue is a rare condition seen most in pubertal, pregnant and breastfeeding women. However, it can arise in pre-adolescent patients and should be added to the differential diagnosis of an axillary mass.

Is Less Actually More? An Evaluation of Surgical Outcomes Between Endoscopic Suturectomy and Open Cranial Vault Remodeling for Craniosynostosis.

BACKGROUND: Both open cranial vault remodeling (CVR) and endoscopic suturectomy are effective in treating the anatomical deformity of craniosynostosis. While parents are increasingly knowledgeable about these 2 treatment options, information regarding the perioperative outcomes remains qualitative. This makes preoperative counseling regarding surgical choices difficult. The purpose of this study was to evaluate the outcomes in patients with craniosynostosis who underwent traditional CVR versus endoscopic suturectomy. METHODS: Open and endoscopic craniosynostosis surgeries performed at our institution from January 2014 through December 2018 were retrospectively reviewed and perioperative data, including operative time, estimated blood loss, transfusion rate and length of stay, was analyzed. A student t test was used with significance determined at P < 0.05. RESULTS: CVR was performed for 51 children while 33 underwent endoscopic procedures. Endoscopic suturectomy was performed on younger patients (3.8 versus 14.0 months, P < 0.001), had shorter operative time (70 versus 232 minutes, P < 0.001), shorter total anesthesia time (175 versus 352 minutes, P < 0.001), lower estimated blood loss (10 versus 28 ml/kg, P < 0.001), lower percentage transfused (42% versus 98%, P < 0.001), lower transfusion volume (22 versus 48 ml/kg, P < 0.001), and shorter length of stay (1.8 versus 4.1 days, P < 0.001) when compared to open CVR. CONCLUSION: Both open CVR and endoscopic suturectomy are effective in treating deformities due to craniosynostosis. The endoscopic suturectomy had significantly shorter operative and anesthesia time as well as overall and PICU length of stay. CVR was associated with greater intraoperative blood loss and more frequently required higher rates of blood transfusions.

A Review and Update of Treatment Options and Controversies in the Management of Hepatocellular Carcinoma.

OBJECTIVE: To review the current management, outline recent advances and address controversies in the management of hepatocellular carcinoma (HCC). SUMMARY OF BACKGROUND DATA: The treatment of HCC is multidisciplinary involving hepatologists, surgeons, medical oncologists, radiation oncologists, radiologists, interventional radiologists, and other disciplines. Each of these disciplines brings its unique perspective and differing opinions that add to controversies in the management of HCC. METHODS: A focused literature review was performed to identify recent studies on the management of HCC and thereby summarize relevant information on the various therapeutic modalities and controversies involved in the treatment of HCC. RESULTS: The main treatment algorithms continue to rely on hepatic resection or transplantation with controversies involving patients harboring early stage disease and borderline hepatic function. The other treatment strategies include locoregional therapies, radiation, and systemic therapy used alone or in combination with other treatment modalities. Recent advances in locoregional therapies, radiation, and systemic therapies have provided better therapeutic options with curative intent potential for some locoregional therapies. Further refinements in combination therapies such as algorithms consisting of locoregional therapies and systemic or radiation therapies are likely to add additional options and improve survival. CONCLUSIONS: The management of HCC has witnessed significant strides with advances in existing options and introduction of several new treatment modalities of various combinations. Further refinements in these treatment options combined with enrollment in clinical trials are essential to improve the management and outcomes of patients with HCC.

Preoperative frailty Risk Analysis Index to stratify patients undergoing carotid endarterectomy.

OBJECTIVE: Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy (CEA) remains problematic. Preoperative variables correlate with increased morbidity and mortality, yet no easily implemented tool exists to stratify patients. We determined the relationship between our fully implemented frailty-based bedside Risk Analysis Index (RAI) and complications after CEA. METHODS: Patients undergoing CEA in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2011 were included. Variables of frailty RAI were matched to preoperative NSQIP variables, and outcomes including stroke, mortality, myocardial infarction (MI), and length of stay were analyzed. We further analyzed patients who were symptomatic and asymptomatic before CEA. RESULTS: With use of the NSQIP database, 44,832 patients undergoing CEA were analyzed (17,696 [39.5%] symptomatic; 27,136 [60.5%] asymptomatic). Increasing frailty RAI score correlated with increasing stroke, death, and MI (P < .0001) as well as with length of stay. RAI demonstrated increasing risk of stroke and death on the basis of risk stratification (low risk [0-10], 2.1%; high risk [>10], 5.0%). Among patients undergoing CEA, 88% scored low (<10) on the RAI. In symptomatic patients, the risk of stroke and death for patients with a score of ≤10 is 2.9%, whereas if the RAI score is 11 to 15, it is 5.0%; 16 to 20, 6.9%; and >21, 8.6%. In asymptomatic patients, the risk of stroke and death for patients with a score of ≤10 is 1.6%, whereas if the RAI score is 11 to 15, it is 2.9%; 16 to 20, 5.2%; and >21, 6.2%. CONCLUSIONS: Frailty is a predictor of increased stroke, mortality, MI, and length of stay after CEA. An easily implemented RAI holds the potential to identify a limited subset of patients who are at higher risk for postoperative complications and may not benefit from CEA.

Abdominal Wall Reconstruction Risk Stratification Tools: A Systematic Review of the Literature.

BACKGROUND: Ventral hernias are a common pathology encountered by surgeons. Multiple risk stratification tools have been developed in attempts to predict a patient's postoperative risk for complication. The aim of this systematic review was to identify published stratification tools, to assess their generalizability, and develop an ensemble risk score model. METHODS: A systematic review of the literature was performed using PubMed and following the PRISMA guidelines. Two independent reviewers identified articles describing hernia stratification tools or validating an established tool. Inclusion criteria included articles that studied ventral hernia risk score models developed through expert consensus or from data of at least 500 subjects, performed a multivariable analysis of at least 500 patients, or assessed a previously reported model. Studies were grouped by primary outcome, and the odds ratios for correlated variables were compiled. Outcomes described in 4 or more articles were then stacked to generate a cumulative risk score model for patients undergoing abdominal wall repair. RESULTS: A total of 20 articles were found to meet our inclusion criteria and used to develop our ensemble model. Surgical-site infection, surgical-site occurrence, and hernia recurrence were the 3 primary outcomes used to calculate our stacked cumulative risk stratification score. CONCLUSIONS: There are multiple risk score tools published; however, all have their strengths and limitations. For this reason, we created a composite score model with data from major articles to predict a patient's risk for postoperative complications. This model aims to ease the shared-decision making process for patients, surgeons, and institutions.

Transanal endoscopic microsurgery and transanal minimally invasive surgery: is one technique superior?

BACKGROUND: Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) have been shown to improve the quality of transanal resections, allowing for improved visibility and access to the proximal rectum. This study compares the short-term outcomes between TEM and TAMIS among experienced colorectal surgeons. METHOD: A retrospective review was conducted for TEM and TAMIS performed from 2012 to 2015 by local colorectal surgeons. Baseline patient demographics, operative variables, pathology results, and short-term outcomes were assessed. RESULTS: Sixty-nine patients were identified (40 TEM and 29 TAMIS). Patient demographics, tumor characteristics, operative variables, margin status, and postoperative complications were similar for both. Volume of resection was higher for TAMIS (P < .001). Lymph node retrieval was achieved in 17.2% of TAMIS cases compared with 0% of TEM (P = .01). CONCLUSIONS: TAMIS appears to have equivalent indications and outcomes compared with TEM. TAMIS is associated with larger specimens and more frequent presence of mesorectal lymph nodes.

Radiographic findings following irrigation of chronic perineal drain with hydrogen peroxide.

INTRODUCTION: Hydrogen peroxide is a widely available agent used for irrigation and disinfecting. With misuse, significant side effects have been noted ranging from nausea to abdominal cramping to portal venous gas, air embolism and death. PRESENTATION OF CASE: We present an 81 year old male who developed a rectovesicular fistula following radiation for metastatic prostate cancer. He had recurrent bleeding and infections and underwent a pelvic exenteration which was complicated by a persistent pelvic abscess requiring placement of a transperineal drainage catheter. After months of persistent drainage, he noted decreased output and irrigated the catheter with 3% hydrogen peroxide. He presented to the emergency room with fever, diarrhea and abdominal cramping but no rebound or guarding. CT depicted free air in the pre-sacral space extending into the retroperitoneum and diffusely throughout the peritoneum. Given his clinical exam and upon review of imaging, we assumed his radiographic findings were related to the direct instillation of hydrogen peroxide into his chronic pelvic cavity. DISCUSSION: Hydrogen peroxide has been used therapeutically for over 100 years. Hydrogen peroxide exerts direct cytotoxicity by corrosion and lipid peroxidation and indirectly by oxygen gas formation. When the oxygen produced exceeds the solubility in the blood, arterial and venous gas embolism occur. It is this sequelae of hydrogen peroxide that is described most frequently in the literature. CONCLUSION: Instillation of hydrogen peroxide into a chronic pelvic cavity resulted in a benign pneumoperitoneum. This effect of hydrogen peroxide is a significant and potentially treatment altering radiographic finding.

Perioperative management of elderly patients.

The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.