Sanjay S. Reddy

Chimeric pedicled latissimus dorsi flap with lateral thoracic lymph nodes for breast reconstruction and lymphedema treatment in a hypercoagulable patient.

Sir: L of the upper extremity after breast cancer treatment has recently become an area of great interest. The reported incidence of lymphedema is approximately 21.4 percent and it generally develops within the first 2 years of treatment for breast cancer.1 Certainly, the risk of lymphedema is much higher with axillary lymph node dissection as opposed to sentinel lymph node biopsy (19.9 percent versus 5.6 percent).1 Additional risk factors for the development of lymphedema include obesity and radiation treatment.2 As the incidence of breast cancer increases with more patients being diagnosed at a younger age, the risk of developing lymphedema is anticipated to increase beyond the current rate of one in five survivors of breast cancer.1 Consequently, there is a tremendous need to develop and perfect therapeutic options to treat those afflicted with this condition. Currently, lymphovenous bypass and vascularized lymph node transfers are the only surgical treatments available.3,4 However, these procedures require microvascular anastomoses. Here, we present a 34-year-old woman with right upper extremity lymphedema resulting from bilateral breast cancer that was initially treated with bilateral lumpectomies, axillary lymph node dissection, and adjuvant radiation therapy. She then underwent bilateral prophylactic mastectomies with immediate tissue expander reconstruction at an outside institution that was complicated by infection and extrusion of the expanders. In addition, she also had a history of multiple pulmonary embolisms and deep venous thromboses. Eventually, she presented to our institution complaining of significant pain and was found to have a 9 percent increase in the size of her right arm compared with the left. Because of her history of venous thromboembolic disease, the microvascular techniques were deemed to be at extremely high risk for increased morbidity and even mortality. The patient underwent bilateral pedicled latissimus dorsi flap reconstruction with transfer of the lateral thoracic lymph nodes on the right side (Fig. 1). The patient’s postoperative course was uncomplicated and she reported complete resolution of her symptoms after 10 weeks. Currently, the patient has experienced a significant reduction in the size of her right arm by 44.4 percent to only being 5 percent larger than her left arm (Fig. 2). Delayed reconstruction with free tissue transfer from the abdomen in conjunction with vascularized lymph node transfer based on the

Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of borderline resectable disease: a commentary on the article published by Kelly et al. In the Journal of Gastrointestinal Surgery 17:1209 (2013).

Dear Editors, We would like to make several comments on the recently published article entitled, Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of “borderline resectable disease”? Although no “final” definitions have been made regarding what defines a borderline resectable cancer, between the MD Anderson, SSO/AHPBA/SSAT, and NCCN consensus, attempts at a uniform classification have been tried. Regardless of the classification system used, these are defined by proper cross-sectional imaging. How many of these patients with venous resection had venous involvement noted on preoperative imaging? If patients did not have venous impingement by imaging, then they should not be classed as borderline resectable (as all definitions include distortion or impingement of the vein). Without accurately knowing the presence or degree of borderline resectability, it is premature to suggest that PV/ SMV involvement be dropped as a criterion for borderline resectability. Chun et al. showed a clear difference in survival in the groups with unilateral portal vein and superior mesenteric vein shifts when treated with neoadjuvant therapy, as compared to a similar group given surgery first. Secondly, the degree of histologic venous involvement was not characterized in the current study. Depth of venous involvement correlates with imaging characteristics and prognosis. Fukuda et al. showed that the depth of vein invasion significantly alters survival after curative resection. Deeper wall invasion into the tunica media or intima was associated with a poorer 1-year survival rate, similar to that of patients undergoing non-curative resection. The present study suggests that on multivariate analysis, vein involvement was not predictive of disease-free or overall survival, but how many of these patients had intimal or medial involvement? Since histologic data is not reported, these patients could all have had no actual histologic venous involvement. The complete answer to this issue would be best obtained by a phase III study of neoadjuvant therapy versus upfront surgery in those with superior mesenteric vein/portal vein compression without occlusion. However, any study examining the issue should surely have both imaging and histologic descriptions of the patients studied.

Trends with neoadjuvant radiotherapy and clinical staging for those with rectal malignancies

AIM To see how patterns of care changed over time, and how institution type effected these decisions. METHODS A retrospective analysis was performed using the National Cancer Database, looking at all patients that were diagnosed with rectal cancer from 1998 to 2011. We tested differences in rates of treatment and stage migration using χ2 tests and logistic regression models. RESULTS A review of ninety thousand five hundred and ninety four subjects underwent multimodality therapy for cancer of the rectum. Staging and response to treatment varied greatly between centers. Forty-six percent of the time staging was missing in academic practices, vs fifty-four percent of the time in community centers (P < 0.001). As a result, twenty-percent were down-staged and eight percent up-staged in academia, whereas only fifteen percent were down-staged and 8% up-staged in community practices (P < 0.001). Forty-two percent of individuals underwent radiation before surgery in 1998. Within two years this increased to fifty-three percent. This increased to eighty-six percent by 2011 (P < 0.001). Institution specific treatment varied greatly. Fifty-one percent received therapy before surgery in academic centers in 1998. Thirty-nine percent followed this pattern in the same year in the community (P < 0.001). By 2011, ninety-one percent received radiation before their procedure in academic centers, vs eighty-four percent in the community (P < 0.001). Rates of adoption were better in academia, although an increase was seen in both center types. CONCLUSION From the study dates of 1998 to 2011, preoperative treatment with radiation has been on the rise. There is certainly an increased rate of use of radiation in academia, however, this trend is also seen in the community. Practice patterns have evolved over time, although rates of assigning clinical stage are grossly underreported prior to initiation of preoperative therapy.

The Utility of Preoperative Vascular Grading in Patients Undergoing Surgery First for Pancreatic Cancer: Does Radiologic Arterial or Venous Involvement Predict Pathologic Margin Status?

Controversy exists on accurately grading vascular involvement on preoperative imaging for pancreatic ductal adenocarcinoma. We reviewed the association between preoperative imaging and margin status in 137 patients. Radiologists graded venous involvement based on the Ishikawa classification system and arterial involvement based on preoperative imaging. For patients with both classifications recorded, we categorized vascular involvement as “None,” “Arterial only,” “Venous only,” or “Both” and examined the association of vascular involvement and pathologic margin status. Of 134 patients with Ishikawa classifications, 63%, 17%, 11%, and 9% were graded as I, II, III, and IV, respectively. Of 96 patients with arterial staging, 74%, 16%, and 10% were categorized as stages i, ii, and iii, respectively. Of 93 patients with both stagings, 61% had no vascular involvement, 7% had arterial only, 14% had venous only, and 17% had both involved. Ishikawa classification was strongly associated with a positive SMA and SMV margin (p<0.001). However, for arterial staging, there was no association with SMA or SMV margin. Overall, Ishikawa grading was more predicative of arterial involvement and remained significant on multivariate analysis. The use of diagnostic imaging in predicting positive margins is more accurate when using a venous grading system.

Lymphoma Causing Gastrosplenic Fistula Revealed by FDG PET/CT

A 73-year-old man presented with fatigue and weight loss. He had CT-proven splenic mass with fistulous connection to the greater curvature of the stomach, which suggested abscess. FDG PET/CT confirmed gastrosplenic fistula in addition to active lymph nodes in the gastrohepatic ligament and epigastric region. Pathological examination after the biopsy of the spleen was consistent with diffuse large B-cell lymphoma. Chemotherapy was administered with close clinical follow-up and resulted in the resolution of fistula without requirement for surgery.

The Role of Heated Intraperitoneal Chemotherapy (HIPEC) in Low-Grade Appendiceal Neoplasm: Friend or Foe?

Low-grade mucinous appendiceal neoplasms are rare tumors. There is limited data on the treatment for pseudomyxoma peritonei with low-grade appendiceal histology. Classifications of appendiceal neoplasms include low-grade appendiceal mucinous neoplasm (LAMN), diffuse peritoneal adenomucinosis (DPAM), and peritoneal mucinous carcinomatosis (PMCA). Studies have demonstrated patients with low-grade appendiceal neoplasms have improved overall survival compared to patients with high-grade appendiceal neoplasms. Since low-grade tumors have better prognosis some retrospective trials have suggested observation in patients with these types of tumors. Another option includes cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). We have done an extensive literature search exploring the various methods in which to treat patients with this disease.

Trends in Therapeutic Endoscopy in Patients with Upper Gastrointestinal Bleeding: Results of All Hospitalizations in California From 1991-2000

Trends in Therapeutic Endoscopy in Patients with Upper Gastrointestinal Bleeding: Results of All Hospitalizations in California From 1991-2000 Sanjay Reddy, Namgyal Kyulo, John Lee Background: only meta-analyses have shown reduction in mortality due to endoscopic therapy because individual studies tended to be under powered. We sought to determine whether endoscopic therapy was associated with reduction in hospital mortality for patients undergoing therapeutic endoscopy in California from 1991-2000. Methods: California Health Data and Advisory Council Consolidation Act mandates that all hospitals licensed in California report details of hospital discharges to the Office of Statewide Health Planning and Development.We used these data to identify all patients hospitalized in California with UGI bleeding (ICD codes 4560-2, 5302, 5310-49) from 1991-2000. Rebleeding was defined as a repeat admission within one year for bleeding occurring from the same source as the initial bleed. Age and gender adjusted incidence rates were calculated using data from the 2000 US Census. This study was approved by the Statewide and the University IRB. Results: Use of endoscopy increased steadily for both variceal (88.8% vs. 93.2%, p ! 0.05) and non variceal bleeding (84.9% vs. 88.4%, p ! 0.05) patients from 1991 to 2000. Similarly the use of endoscopic therapy increased for both variceal (46.3% vs. 58.6%) and non variceal bleeding (15.3% vs. 26.2%) patients. Fewer patients with variceal bleeding (14.6% vs. 5.6%) required two or more endoscopies during the hospitalization from 1991 to 2000; the rate of repeat endoscopy remained steady for non variceal bleeding (6.3% to 7.2%) patients. Endoscopy tended to be performed earlier for both groups over the study period (1.2 vs. 1.0 d after admission for the variceal group and 1.4 vs. 1.2 d for the non variceal group).There were no significant mortality trends for patients with variceal bleeding. Non variceal bleeding patients who required only one endoscopy had significantly lower hospital mortality compared to those who required two or more endoscopies (3.2% vs. 7.1%, p Z 0.001).Within the groups of patients who had only one endoscopy during admission, the mortality showed a trend in reduction from 4.0% in 1991 to 3.2% in 2000. Conclusion: More patients Abstracts