James E. Goodnight

Tumors of the Retrorectal Space

PURPOSERetrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential.METHODSThe incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis.RESULTSRetrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions.CONCLUSIONSRetrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Women Surgeons in the New Millennium

BACKGROUND Women are increasingly entering the surgical profession. OBJECTIVE To assess professional and personal/family life situations, perceptions, and challenges for women vs men surgeons. DESIGN National survey of American Board of Surgery-certified surgeons. PARTICIPANTS A questionnaire was mailed to all women and men surgeons who were board certified in 1988, 1992, 1996, 2000, or 2004. Of 3507 surgeons, 895 (25.5%) responded. Among these, 178 (20.3%) were women and 698 (79.7%) were men. RESULTS Most women and men surgeons would choose their profession again (women, 82.5%; men, 77.5%; P = .15). On multivariate analysis, men surgeons (odds ratio [OR], 2.5) and surgeons of a younger generation (certified in 2000 or 2004; OR, 1.3) were less likely to favor part-time work opportunities for surgeons. Most of the surgeons were married (75.6% of women vs 91.7% of men, P < .001). On multivariate analysis, women surgeons (OR, 5.0) and surgeons of a younger generation (OR, 1.9) were less likely to have children. More women than men surgeons had their first child later in life, while already in surgical practice (62.4% vs 32.0%, P < .001). The spouse was the offsprings primary caretaker for 26.9% of women surgeons vs 79.4% of men surgeons (P < .001). More women surgeons than men surgeons thought that maternity leave was important (67.8% vs 30.8%, P < .001) and that child care should be available at work (86.5% vs 69.7%, P < .001). CONCLUSIONS Women considering a surgical career should be aware that most women surgeons would choose their profession again. Strategies to maximize recruitment and retention of women surgeons should include serious consideration of alternative work schedules and optimization of maternity leave and child care opportunities.

Dermatofibrosarcoma protuberans: reappraisal of wide local excision and impact of inadequate initial treatment.

Background: The extent of local invasion in dermatofibrosarcoma protuberans (DFSP) is often clinically difficult to appreciate, and this leads to inadequate resections. We examined the effect of inadequate initial treatment and the efficacy of wide resection.Methods: We performed a retrospective analysis of the records of 35 patients with DFSP treated at our institution (1985 and 2001). Data were analyzed with Wilcoxon’s ranked sum test and Fisher’s exact test.Results: Of the 24 patients eligible for analysis, 11 had definitive wide resection after diagnostic excisions elsewhere (primary group), and 13 had recurrent tumors after previous surgical treatment elsewhere (recurrent group). Twenty-three patients were treated with wide resection only, and adjuvant radiation was administered to one patient who had a fibrosarcoma. At a median follow-up of 54 months, patients definitively treated at our institution had a 100% local recurrence–free survival. In comparison to the primary group, recurrent DFSPs were significantly larger and deeper and occurred in the head and neck region. Five cases had bone involvement, and of these, 80% occurred in the recurrent group.Conclusions: Inadequate initial treatment results in larger, deeper recurrent lesions, but these can be managed by appropriate wide excision. Wide resection of DFSP (whether recurrent or primary) with negative histological margins predicts a superior local recurrence–free survival.

Minimally invasive Ivor Lewis esophagectomy

Ivor Lewis esophagectomy consists of a laparotomy and right thoracotomy for resection of the intrathoracic esophagus. Recent advances in minimally invasive surgical technology have allowed surgeons to apply laparoscopy and thoracoscopy to perform esophagectomy. However, there have been few reports that describe a totally minimally invasive Ivor Lewis esophagectomy. We present a case of combined laparoscopic and thoracoscopic resection of the distal third esophagus with an intrathoracic esophagogastric reconstruction for esophageal carcinoma.

Limb-sparing surgery for extremity sarcomas after preoperative intraarterial doxorubicin and radiation therapy☆

Complete local control of 25 extremity bone and soft tissue sarcomas was obtained by combined preoperative intraarterial doxorubicin and radiation therapy, followed by limb-sparing resection with reconstruction and adjuvant chemotherapy. At a 32 month median follow-up, there are no local tumor recurrences. Functional limbs were salvaged in 21 patients (84 percent). Fifteen patients (60 percent) were continuously disease-free and overall survival was 80 percent. After the extensive combined modality therapy, extremity complications, including delays in wound healing, occurred in 10 patients. Nevertheless, most complications were resolved with salvage of functional limbs. These results support an aggressive multimodality limb-sparing approach to high-grade extremity sarcomas.

Multimodality management of a giant cell tumor arising in the proximal sacrum: case report.

Study Design. Descriptive. Objective. To outline a novel multimodality approach for a difficult surgical resection of a giant cell tumor in the cephalad portion of the sacrum. Summary of Background Data. Giant cell tumors of the sacrum are rare primary bone tumors. Recent reports have demonstrated diminished giant cell tumor recurrence with cryosurgery by using a “direct pour” technique with liquid nitrogen. Although successful in decreasing tumor recurrence, this technique is accompanied by a 4%–8% rate of skin necrosis and high rates of pathologic fracture. The authors describe resection and a novel, controlled method of argon-based cryotherapy (followed by a unique pelvic reconstruction) for a large, difficult giant cell tumor of the sacrum. Methods. A 29-year-old woman presented with complaints of right foot drop and decreased sensation of the right buttock, posterior thigh, posterior calf, and lateral aspect of the right foot. Radiographic evaluation revealed a mass in the right sacrum; histologic examination of CT-guided biopsy revealed a giant cell tumor. A combined anterior abdominal and posterior sacral approach was performed, the tumor was resected, and the margin of the cavity was treated with controlled argon-based cryotherapy. The combination of thermocouples, electromyographic monitoring, and rapid freeze–thaw cycles allowed a controlled ablation of the tumor margin while ensuring that surrounding structures, such as the rectal wall, sacral nerves, and gluteal muscles, were not damaged. Posterior spinal fusion L4 to sacrum, posterior spinal instrumentation L4 to pelvis, and allograft reconstruction of the right sacrum were performed. Results. The patient recovered well without skin necrosis or pathologic fracture. Urinary and fecal continence were preserved. At the 20-month follow-up the patient has no evidence of local tumor recurrence and is fully ambulatory without a brace or narcotic medication. Conclusion. A novel multimodality approach, consisting of resection, controlled cryosurgery, and a unique lumbopelvic reconstruction, was safe and successful in managing a challenging proximal sacral giant cell tumor. Twenty months after surgery the patient has excellent bowel and bladder control, no tumor recurrence, and functional ambulation without a brace or pain.

Racial and ethnic differences in treatment and survival among adults with primary extremity soft-tissue sarcoma

Limb preservation is preferred to amputation for patients with extremity soft tissue sarcoma (ESTS). Disparities in the treatment and outcomes of several malignancies have been reported, but not for ESTS. The authors assessed racial/ethnic differences in patient‐ and tumor‐specific characteristics, treatment, and disease‐specific survival in a population of adults with ESTS.

Evaluation of minimally invasive surgical staging for esophageal cancer

BACKGROUND Conventional imaging studies (computed tomography and endoscopic esophageal ultrasonography) used for preoperative evaluation of patients with esophageal cancer can be inaccurate for detection of small metastatic deposits. We evaluated the efficacy of minimally invasive surgical (MIS) staging as an additional modality for evaluation of patients with esophageal cancer. METHODS Between December 1998 and February 2001, 33 patients with esophageal cancer were evaluated for surgical resection. Conventional imaging studies demonstrated operable disease in 31 patients and equivocal findings in 2 patients. All patients then underwent MIS staging (laparoscopy, bronchoscopy, and ultrasonography of the liver). We compared the results from surgical resection and MIS staging with those from conventional imaging. RESULTS MIS staging altered the treatment plan in 12 (36%) of 33 patients; MIS staging upstaged 10 patients with operable disease and downstaged 2 patients with equivocal findings. MIS staging accurately determined resectability in 97% of patients compared with 61% of patients staged by conventional imaging. The specificity and negative predictive value for detection of unsuspected metastatic disease in MIS staging were 100% and 96%, respectively, compared with 91% and 65%, respectively, for conventional imaging studies. CONCLUSION In addition to conventional imaging studies, MIS staging should be included routinely in the preoperative work-up of patients with esophageal cancer.

A simplified technique to resect abnormal bony radiolocalizations using a gamma counter

A simplified technique for localizing and verifying the correct biopsy site of lesions identified on a bone scan has been utilized. A hand-held gamma counter was used for localization of incision placement, determination of extent of bone to be resected, and verification that appropriate tissue was resected. This technique was used to guide biopsy of bony lesions in five patients and to guide resection of a pubic ramus chondrosarcoma. We conclude that intraoperative use of a gamma counter to guide biopsy of bony lesions minimizes surgery time, increases the confidence of obtaining correct tissue, and makes a frequently frustrating procedure very simple. In addition, the probe may assist with determining adequate margins at definitive resection of tumours which accumulate technetium-99m MDP.

Hilar cholangiocarcinoma: surgical and endoscopic approaches

HCCa remains an uncommon malignancy, though increasing use of more radical surgery has led to prolonged survival in those patients who undergo curative resection. The extent of these resections suggest that the best results are likely to be obtained in centers with the resources and experience to conduct these operations in a safe fashion. Until major advances in the systemic therapy of HCCa are made, however, the management should focus on optimal preoperative imaging and palliation of jaundice with improvement in quality of life.