Austin L. Chiang

Improving Access to Care: Breast Surgeons, the Gatekeepers to Breast Reconstruction

BACKGROUND Fewer than half of patients undergo reconstruction after breast cancer treatment, despite its quality of life benefits. Earlier studies demonstrated that most general surgeons do not discuss reconstructive options with patients. The aim of this study was to examine the likelihood of reconstruction within a cohort of mastectomy patients and compare rates of reconstruction between those referred and not referred for plastic surgery evaluation. STUDY DESIGN Retrospective review of the records of 471 consecutive patients between the ages of 19 and 94 years who underwent mastectomy between 2003 and 2007. Variables evaluated were age, body mass index, diabetes, laterality (unilateral vs bilateral), TNM staging, history of radiation, smoking history, insurance type, and race. RESULTS Of 471 patients, 313 were referred for consultation with a plastic surgeon and 158 were not; 91.7% of those referred were reconstructed and 100% of those not referred were not reconstructed. The 2 groups differed considerably in terms of age (mean age 61.84 years in the nonreferred group vs 51.83 years in the referred group), body mass index (25.9 in referred group, 27 in nonreferred group), diabetes (15% in nonreferred group vs 3.5% in referred group), and laterality (14% of nonreferred group underwent bilateral mastectomies vs 26% of those referred). The groups did not differ significantly in terms of race or tobacco use. Those with private insurance were more likely to be reconstructed, but no independent effect of insurance type was seen on multivariate analysis. CONCLUSIONS The breast surgeons decision to refer a patient for reconstruction significantly affects whether the patient will receive breast reconstruction. Factors that appear to influence the referral decision are age, diabetes, body mass index, and laterality of mastectomy (bilateral more than unilateral).

Procedural variation in the performance of primary percutaneous coronary intervention for ST‐elevation myocardial infarction: A SCAI‐based survey study of US interventional cardiologists

Great strides have been made in improving outcomes for patients with ST‐elevation myocardial infarction (STEMI), predominately through initiatives focusing upon improving clinical processes “upstream” of percutaneous coronary intervention (PCI). The actual step‐by‐step mechanics of diagnostic angiography during STEMI and other aspects of the PCI procedure itself have received relatively little attention.

Examining reduction mammaplasty in Hispanic and African American populations: A changing landscape in American plastic surgery

As 21st century physicians, we are witnessing a change in the American landscape with an increased proportion of non-Caucasian patients, particularly Black and Hispanic individuals. The Census Bureau predicts that by 2050, the American population will be one quarter Hispanic, yet the plastic surgical literature rarely addresses this growing population. We aimed to determine if specific factors in this population influence preoperative planning and counseling, guide intra-operative decisions, or affect surgical outcomes. Following approval by the Institutional Review Board at Columbia University Medical Center, the authors performed a retrospective chart review of consecutive breast reduction cases completed at a single center between 2003 and 2007. Patient charts were evaluated for demographic background, pre-operative complaints and counseling, operative techniques, pathology specimens, and postoperative complications and outcomes. The method of breast reduction chosen was determined by projected nipple movement, estimated reduction weight, and patient/surgeon preference (JA, JW, CR). Post-operatively, patients had scheduled office appointments at 1-2 weeks, 6 wks, at 6 months, and then yearly. 161 patients underwent reduction mammaplasty. 116 (72%) of the patients classified themselves as nonCaucasian. (Table 1) All patients were followed for at least one year. The mean age was 35 years for nonCaucasians and 38 years for Caucasians (p Z ns). NonCaucasian women had a significantly higher body-massindex (BMI Z kg/m) and body-surface-area (BSAZ[Height (cm) Weight (kg)]/3600) than their Caucasian counterparts. Non-Caucasian women were more likely to have a history of smoking and have larger brassiere band sizes. Non-Caucasian patients were more likely to complain of

Treatment of recurrent esophageal stricture with an insulated-tip electrosurgical knife and mitomycin C

An 82-year-old woman presented with dysphagia due to a refractory esophageal stricture. The stricture was thought to have been caused 2 years previously after hospitalization for a hip fracture and prolonged nasogastric tube placement at a subacute care facility. Numerous attempts at stricture dilation, initially every 2 weeks, had been made at another institution using a hydrostatic balloon and an esophageal stent, which was later removed because of complications. At our center, the patient underwent upper gastrointestinal (GI) endoscopy under general anesthesia, during which a severe benign-appearing intrinsic stenosis (4-mm wide and 1-cm long) that prohibited passage of the endoscope was encountered 31 cm from the incisors (▶Video1). The stenosis was incised using an insulated-tip electrosurgical knife along the aspect opposite to the aorta. Balloon dilation was performed to a diameter of 15mm before the stenosis was traversed and a 4-cm hiatus hernia was noted. The remainder of the upper GI endoscopy was normal. Repeat balloon dilation to 15mm was then performed. The upper GI endoscope was removed and an overtube was advanced to the level of the stricture to minimize mucosal contact with mitomycin C. A gauze soaked with 1mL of mitomycin C solution (0.4mg/mL) was delivered to the level of stricture with a rat-toothed forceps that was fed through the endoscope (▶Fig. 1). The gauze was applied to the level of the stenosis for 3 minutes and this was followed by a second 2-minute treatment. The patient was discharged home on a full liquid diet for 2 days followed by soft diet for 2 days. She was seen in clinic 7 months later with no recurrent symptoms. Esophageal stricture due to prolonged nasogastric tube placement has been previously reported [1]. Data on the use of topical mitomycin C for esophageal strictures are limited, but similar techniques have been shown to be safe and effective in children with strictures due to caustic injury or after repair of esophageal atresia [2–5]. Endoscopy_UCTN_Code_TTT_1AO_2AN

Endoscopic full-thickness resection of fistula tract with suture closure

A 59-year-old man, with a history of Roux-en-Y gastric bypass 9 years previously, presented with chronic epigastric pain thought to be due to recurrent marginal ulceration. On diagnostic endoscopy he was found to have a 3-cm gastric pouch and a 18-mm gastrojejunal anastomotic diameter. Additionally, a 1-cm cratered ulceration on the jejunal aspect of the post-bypass anastomosis and a 3-mm fistulous opening in the distal gastric pouch were noted. The presence of bubbles when the area was flooded with water suggested a fistulous communication between the gastric pouch and the remnant stomach. The area was injected with diluted 1:10000 epinephrine mixed with methylene blue to lift the fistulous opening. An electrosurgical knife was used to create an incision in the mucosa, and an insulated-tip needle-knife was used to encircle the area. Standard endoscopic submucosal dissection technique was used. The tissue was brought into a snare using forceps, and the fistulous tract and the surrounding dissected mucosa was resected with snare cautery (▶Video1). The resected site was closed with a running stitch created using an endoscopic suturing device, and 3 additional interrupted reinforcement stitches were placed. The patient’s abdominal pain resolved 2 weeks after the procedure. An upper gastrointestinal series 3 months later confirmed closure of the fistula and evidence of recurrent marginal ulceration. Gastrogastric fistula is a recognized complication of gastric bypass. However, fistula closure rates remain low with current endoscopic treatment methods. One initial study of endoscopic fistula closure in 95 patients showed recurrent fistula in 65% [1]. Another multicenter trial using a full-thickness endoscopic suturing device alone (n =29) showed 100% immediate technical success but a closure rate of 17.1% after 12 months [2]. The novel technique described here utilizes surgical principles by combining endoscopic submucosal dissection together with fistula tract resection, which may allow for better apposition of healthier tissue and improve successful long-term closure.

Autoimmune Pancreatitis Presenting as Multifocal Masses, Diagnosed on Ampullary Biopsy.

10 million in the general population. VIPomas secrete excessive amounts of VIP and cause a large volume of watery diarrhea in nearly 100% of patients, hypokalemia in 70% to 100% of patients, and dehydration in 30% to 100% of patients. In 1 previous report, the median survival of patients was 3.6 years (the longest survival was 15 years), and in another study, the 5-year actuarial survival rate was 69%. The definitive treatment for VIPoma is surgical removal of the tumor; however, when curative resection is not possible, somatostatin analog therapy is the mainstay of treatment to inhibit endocrine hyperfunction. The prevalence of PNET associated with IPMN is low and has been reported as 2.8% to 4.6% by previous studies. However, recent studies have reported that both pancreatic tumors are rare, and thus, this association seems to occur more frequently than it would be expected by chance. Conversely, it may be argued that the occurrence of concomitant IPMN and PNET is simply coincidental. One reason for this is that the incidence of small, incidental PNETs is probably higher than previously thought; the frequency of nonfunctioning PNETs has been reported to be up to 10% in autopsy series. Recently, the genetic basis of IPMN and PNETs was determined. Wu et al reported that mutations inGNAS andKRAS are present in 66% and 81% of IPMNs, respectively, and that the most commonly mutated gene is RNF43. In contrast, Jiao et al reported that the most commonly mutated genes in PNETs areMEN1,DAXX, and ATRX, and genes in the mTOR pathway. Approximately 43% of cases of PNET have a mutation inDAXX orATRX pathway genes. These results suggest that there are obvious differences between the genetic landscapes of PNET and IPMN. However, the data available about the genetic aspects of these tumors are insufficient to conclude that the incidence of this association is more than just fortuitous. In conclusion, IPMN and PNET rarely coexist, and all of the previously reported concomitant cases of IPMN and PNET were nonfunctioning; for example, PNET was not associated with hormone-excess syndrome. This is the first report of concomitant IPMN and functioning PNET.

Endoscopic treatment of obesity.

Purpose of review Obesity and its comorbid illnesses affect millions worldwide and are one of the major causes of preventable death in the world. Bariatric surgery is currently offered to individuals with a BMI greater than 40 kg/m2 or greater than 35 kg/m2 with obesity-related comorbidities such as hypertension or diabetes. Endoscopic bariatric therapies, with their reduced invasiveness and potential reversibility, may complement surgical approaches for achieving weight loss. Recent findings At the time of this writing, two endoscopically placed intragastric balloons and an endoscopically placed aspiration tube have been approved by the Food and Drug Administration for weight loss purposes. Some devices employ a suturing platform to create plications or to appose two surfaces. Other endoscopic strategies under investigation to treat obesity-related comorbidities such as diabetes include duodenal mucosal resurfacing and creation of a partial jejunoileal diversion using self-assembling magnets. Summary Current endoscopic methods for the treatment of obesity utilize various mechanisms, including occupying gastric volume, reducing gastric capacity, altering caloric absorption, or aspirating gastric contents. The long-term outcomes and cost-effectiveness of these strategies remain to be fully elucidated. The landscape of endoscopic bariatric therapies continues to evolve.