Elisabeth C. McLemore

Breast Cancer: Presentation and Intervention in Women With Gastrointestinal Metastasis and Carcinomatosis

BackgroundBreast cancer metastatic to the gastrointestinal tract or peritoneum is rare. We reviewed the natural history of ductal and lobular carcinoma in women with breast cancer metastatic to the gastrointestinal tract, peritoneum, or both.MethodsWe performed a retrospective review of all patients (1985–2000) with a pathologic diagnosis of breast cancer metastatic to the gastrointestinal tract or peritoneum. Patients were categorized into three groups: those with gastrointestinal metastasis, carcinomatosis, or both.ResultsOf 73 patients, 23 (32%) had gastrointestinal metastasis only, 32 (44%) had carcinomatosis only, and 18 (25%) had both. The median age at initial breast cancer diagnosis was 55 years. The mean interval between the primary diagnosis and metastatic presentation was 7 years. Sites of gastrointestinal metastases included the esophagus (8%), stomach (28%), small intestine (19%), and colon and rectum (45%). Infiltrating lobular carcinoma represented 34 (64%) of the 53 gastrointestinal metastases. The median overall survival after diagnosis was 28 months. Palliative surgical intervention in 47 patients (64%) did not affect overall survival. Some survival benefit may have accrued to select patients with gastrointestinal metastasis who underwent surgical palliation (44 vs. 9 months). Advanced age at diagnosis and gastric metastases had a negative effect on survival, whereas treatment with systemic chemotherapy or tamoxifen had a positive effect on survival.ConclusionsGastrointestinal metastasis occurred more often in patients with invasive lobular carcinoma. Surgical intervention did not significantly extend overall survival but may be considered in a select group of patients.

Laparoscopic parastomal hernia repair.

BackgroundManagement of the parastomal hernia represents a common clinical dilemma for both the surgeon and patient. Once established, these defects are notoriously difficult to treat. Although most parastomal hernias can be managed nonoperatively, approximately 30% will require intervention secondary to complications such as obstruction, pain, bleeding, poorly fitting appliances, or leakage. Overall complication rates of up to 88%, combined with a growing body of literature citing decreased patient morbidity and improved outcomes with laparoscopic tension-free mesh repair of ventral hernias, have led many surgeons to apply these techniques to this difficult problem.MethodsThis was a retrospective review of 21 consecutive patients who underwent laparoscopic repair of their parastomal hernias with ePTFE mesh.ResultsNine (43%) were ileal conduits, seven (33%) were ileostomies, and five (24%) were colostomies. Eight patients had undergone prior hernia repair. Follow-up ranges from 1 to 36xa0months (average 14xa0months). There has been one recurrence (5%). Other complications included laparoscopic re-operation for obstruction of a urinary conduit (nxa0=xa01), mesh removal for infection (nxa0=xa02), Clostridium Difficile colitis (nxa0=xa01), pneumonia (nxa0=xa02), renal failure (nxa0=xa01), surgical site infection (nxa0=xa01), and bowel obstruction at a site remote from the hernia repair (nxa0=xa02).ConclusionThe laparoscopic approach to parastomal hernias is a new technique that offers many potential advantages over conventional open repairs. Based on our initial experience, this repair seems to be associated with a low recurrence rate.

Parastomal Hernia: Short-Term Outcome After Laparoscopic and Conventional Repairs

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 ± 58 vs 162 ± 114 minutes, P = .06). The mean length of stay was 6 days for both groups (P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P ≤ .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.

Anterior mediastinotomy for parathyroidectomy.

BACKGROUNDnApproximately 2% of ectopic parathyroid glands reside within the mediastinum in a location that requires a thoracic approach.nnnMETHODSnAll patients with mediastinal parathyroid tumors who underwent anterior mediastinotomy were included in this review.nnnRESULTSnOver the course of 16 years, 10 patients with primary hyperparathyroidism underwent anterior mediastinotomy. There were 6 men and 4 women with a median age of 65. Seven patients had undergone at least one previous cervical exploration. Preoperative calcium levels were 11.3 +/- .8 mg/dL. Nine patients had preoperative localization with radionuclide scans and 9 patients also had preoperative computerized tomography or magnetic resonance imaging scans. An abnormal gland was removed in all cases. Nine of 10 patients had normalization of their calcium levels.nnnCONCLUSIONSnAnterior mediastinotomy after preoperative imaging has proven to be a technically feasible, safe, and effective method for the surgical management of patients with sporadic primary hyperparathyroidism and mediastinal parathyroid tumors.