Angelena Crown

Local resection for duodenal gastrointestinal stromal tumors

BACKGROUND Duodenal gastrointestinal tumors (GIST) present infrequently, and surgical resection with negative margins remains the mainstay of therapy; however, given the lack of lymphatic and submucosal spread and anatomic location near the bile duct and pancreas, the optimal approach for resection is unknown. Options include local resection (LR), segmental resection, and pancreaticoduodenectomy (PD). METHODS All cases of gastrointestinal stromal tumors originating from the duodenum from 2000 to 2015 were identified from administrative databases. Clinical and pathologic information was abstracted from the medical record and compared between patients who received LR vs PD. The chi-square with Fishers exact test was used to detect differences between groups. RESULTS Fifteen patients met the inclusion criteria, of which 7 had an LR and 8 had a PD. The second portion of the duodenum was the most common origin of GIST in the PD group, whereas the third portion was most common in the LR group. Patients who underwent LR tended to be younger, but there was no difference in tumor size, mitotic rate, margin positivity, readmission rate, or recurrence. PD was associated with more complications, higher blood loss, and longer length of stay. CONCLUSIONS Local resection is a reasonable option for resection of duodenal GIST and should be routinely considered if technically feasible.

Association of Intraoperative Radiotherapy in the Treatment of Early-Stage Breast Cancer With Minor Surgical Site Complications in Oncoplastic Breast-Conserving Surgery

process issues rather than clinician-level errors.5 Processfocused, hospitalwide MMCs may be particularly useful in countries, such as Armenia, with a high density of surgeons and where competition among clinicians may be a significant barrier. In addition, collaboration between medical specialists and surgeons may improve systemwide and hospitalwide adoption of MMCs. This study was limited by the use of a nonvalidated survey and the possibility of an observer effect. Nevertheless, our survey identified significant barriers to implementing MMCs in Armenia, particularly concerns over confidentiality and the legal repercussions of disclosing medical errors.

Influence of carcinoid syndrome on the clinical characteristics and outcomes of patients with gastroenteropancreatic neuroendocrine tumors undergoing operative resection

Background: The incidence, clinical characteristics, and long‐term outcomes of patients with gastroenteropancreatic neuroendrocrine tumors and carcinoid syndrome undergoing operative resection have not been well characterized. Methods: Patients undergoing resection of primary or metastatic gastroenteropancreatic neuroendrocrine tumors between 2000 and 2016 were identified from an 8‐institution collaborative database. Clinicopathologic and postoperative characteristics as well as overall survival and disease‐free survival were compared among patients with and without carcinoid syndrome. Results: Among 2,182 patients who underwent resection, 139 (6.4%) had preoperative carcinoid syndrome. Patients with carcinoid syndrome were more likely to have midgut primary tumors (44.6% vs 21.4%, P < .001), lymph node metastasis (63.4% vs 44.3%, P < .001), and metastatic disease (62.8% vs 26.7%, P < .001). There was no difference in tumor differentiation, grade, or Ki67 status. Perioperative carcinoid crisis was rare (1.6% vs 0%, P < .01), and the presence of preoperative carcinoid syndrome was not associated with postoperative morbidity (38.8% vs 45.5%, P = .129). Substantial symptom improvement was reported in 59.5% of patients who underwent curative‐intent resection, but occurred in only 22.7% who underwent debulking. Despite an association on univariate analysis (P = .04), carcinoid syndrome was not independently associated with disease‐free survival after controlling for confounding factors (hazard ratio 0.97, 95% confidence interval 0.64–1.45). Preoperative carcinoid syndrome was not associated with overall survival on univariate or multivariate analysis. Conclusion: Among patients undergoing operative resection of gastroenteropancreatic neuroendrocrine tumors, the prevalence of preoperative carcinoid syndrome was low. Although operative intervention with resection or especially debulking in patients with carcinoid syndrome was disappointing and often failed to improve symptoms, after controlling for markers of tumor burden, carcinoid syndrome was not independently associated with worse disease‐free survival or overall survival.

Clinical and radiological follow-up rather than excisional biopsy is reasonable after complete papilloma excision at the time of core needle biopsy

Papillary lesions of the breast account for fewer than 1% of findings on core needle biopsy (CNB) and may carry precancerous potential. Papillary lesions comprise a spectrum of entities including intraductal papilloma (IDP), IDP with atypia, and papillary carcinomas (Figure 1). Recent studies strongly support excisional biopsy of IDP with atypia given the high rate of upstage to malignancy, reported to be as high as 30%. Rate of upstage excision of IDP without atypia at the time of surgical excision ranges from 7%-37.5% for atypia and 3%-17% for malignancy. As a result, many groups have advocated for routine surgical excision of all IDPs regardless of the presence or absence of atypia as all papillary lesions may harbor small malignant foci. Other groups have attempted to elucidate patient factors such as young age and lesion characteristics such as pathologic and radiologic concordance and lesion size to predict benign behavior and obviate need for surgical excision. The primary aim of our study was to evaluate whether radiologic follow-up was sufficient for IDPs without atypia that were completely excised at the time of CNB. We performed a single institution chart review which identified all high-risk lesions diagnosed on CNB specimens between January 2007 and December 2014 from an institutional data base. We identified 125 patients with IDP without atypia. Fisher’s exact tests were used to compare categorical data. Unpaired two-tailed student’s t tests were used to analyze continuous variables. Excisional biopsy was performed in 102 patients with IDP without atypia. A total of 2 patients (2.0%) were upstaged to malignancy (1 ductal carcinoma-in-situ and 1 invasive ductal carcinoma) and 12 patients (11.8%) had atypia on final surgical pathology. Patient age ranged from 16 to 90 years with an average of 56 years. Lesion size ranged from 1 to 50 mm with an average size of 8.9 mm. There was no difference in patient age, size of lesion, as well as the presence of calcifications or sclerosis on CNB between patients who were upstaged and those whose final specimen demonstrated IDP without atypia (Table 1). Of the 17 patients whose IDP were completely excised by CNB, 12 went on to excisional biopsy and none was upgraded to atypia or F IGURE 1 Papilloma with central fibrovascular core surrounded by myoepithelial and epithelial layers [Color figure can be viewed at wileyonlinelibrary.com]

Oncoplastic reduction mammaplasty, an effective and safe method of breast conservation

INTRODUCTION Oncoplastic breast conserving surgery (BCS) can enhance both cosmetic and oncologic breast cancer outcomes. This study evaluates the outcomes and complications associated with oncoplastic reduction mammaplasty performed by surgical breast oncologists. METHODS A single institution retrospective chart review of patients undergoing oncoplastic reduction mammaplasty by a surgical breast oncologist for the treatment of breast cancer. RESULTS Seventy-one patients were identified. The average patient age was 59.6 years (range 37-77 years). Average lesion span was 31.4 mm (range 3-166 mm). Six (8.5%) patients required additional surgery to obtain adequate margins. One (1.4%) patient developed recurrent disease during the follow-up interval. No major surgical complications were observed. CONCLUSION Oncoplastic reduction mammaplasty is associated with low rates of re-excision and complications and can be safely and effectively performed by appropriately trained surgical breast oncologists.

Oncoplastic breast conserving surgery is associated with a lower rate of surgical site complications compared to standard breast conserving surgery

BACKGROUND Oncoplastic breast conserving surgery (OBCS) integrates plastic surgery techniques in the resection of breast cancer and lowers the rate of re-excision while improving breast cosmesis. The goal of this study is to compare the surgical site complication rate of OBCS with that of standard BCS. METHODS A single institution chart review evaluated all patients undergoing BCS for treatment of breast cancer. Patients treated from January 2009 to December 2010, prior to adoption of oncoplastic techniques, were identified as the standard surgery (SS) group. Patients treated with OBCS from January 2013 to July 2015 were identified as the oncoplastic surgery (OS) group. All surgical site complications were recorded. RESULTS Overall, 561 patients were evaluated. The SS group comprised 273 patients compared with 288 patients in the OS group. Surgical site complications occurred in 49 patients (17.9%) in the SS group compared with 23 patients (8.0%) in the OS group (p < 0.001). DISCUSSION Overall, BCS has a low rate of significant surgical site complications. OBCS has a lower rate of surgical site complications compared to standard BCS.

Extracorporeal life support is safe in trauma patients

INTRODUCTION The role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS. METHODS Data from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients. RESULTS Eighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p=0.018) and had a shorter median total hospital length of stay (8days non-survivors vs. 32days survivors, p<0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival. CONCLUSIONS Extracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.

Circumferential pedicled omental flap for protection of portomesenteric venous reconstruction and gastroduodenal artery stump following pancreatoduodenectomy

Abstract This video demonstrates a technique for creation of an omental tissue barrier to protect a portomesenteric vein reconstruction or gastroduodenal artery (GDA) stump. Following routine pancreatoduodenectomy reconstruction, a generous tongue of omentum is mobilized off the transverse colon ensuring to preserve the feeding branches from the left gastroepiploic artery. The omentum is then passed behind the pancreatojejunostomy above the vein repair site. It is grasped superiorly and passed anterior to the pancreatojejunostomy to exclude the GDA stump. The flap is then secured to the blind end of the jejunum with suture thereby completing the circumferential wrap. Care must be taken in obese patients to trim the flap so it can fit behind the pancreas without devascularizing it or causing tension on the pancreatojejunostomy. If a closed suction drain is desired, it can be passed from the patients right either in front of or behind the hepaticojejunostomy and placed around the flap. This technique is most applicable to patients with moderate to high risk of pancreatic fistula (small pancreatic duct and/or soft gland) after undergoing PD with an intact omentum. This circumferential, pedicled omental flap is an easy, reproducible, and durable method to protect vascular structures and repairs from pancreatic fistulas.

Comparative analysis of resected duodenal and ampullary adenocarcinoma.

362 Background: Duodenal and ampullary adenocarcinomas are rare gastrointestinal cancers that share similar anatomic location and treatment strategy. We report a single-institution experience regarding the association between clinicopathologic features, treatment, and survival outcomes. Methods: A retrospective review of all patients resected with curative intent for duodenal adenocarcinoma (DUO) between 2005-2015 and ampullary adenocarcinoma (AMP) between 2011-2015 at VMMC was performed. For AMP, histologic subtyping into intestinal (IT) and pancreatobiliary (PB) phenotypes was determined. Demographic and clinicopathologic parameters were compared between DUO and AMP patients using Chi-square test. Overall survival was calculated using Kaplan-Meier analysis and prognostic factors were identified by univariate Cox regression. Results: Patients with DUO (n = 44) presented at higher T-stage (p = 0.002) and with larger tumors (4.35cm vs 2.33cm, p < 0.001) than AMP patients (n = 46). DUO patients had a higher...