Seth A. Spector

Results of 23,810 Cases of Ductal Carcinoma-in-situ

BackgroundScreening mammography has increased the number of patients diagnosed with ductal carcinoma-in-situ (DCIS) in the past 20 years. The Florida Cancer Data System is the largest single source incident cancer registry in the United States. We analyzed this registry to determine the changing incidence and treatment patterns for DCIS.MethodsPatients with DCIS from 1981 to 2001 were identified. Age-adjusted rate, descriptive statistics, and incidence of future DCIS and invasive breast cancer were calculated.ResultsA total of 23,810 DCIS patients were identified. The age-adjusted rate of DCIS has risen from 2.4 to 27.7 per 100,000 women between 1981 and 2001. Median age was 64 years; 85% of patients were white, 6.6% African American, and 7.5% Hispanic. Median tumor size was .9 cm. Forty-seven percent of patients had breast-conserving therapy (BCT). Half of the 53% of patients undergoing mastectomy underwent a modified radical mastectomy. Eight percent received no surgical treatment. Sentinel lymph node biopsy was used in 2.7% of patients who underwent a mastectomy. After BCT, 37.5% received adjuvant radiotherapy, and only 13% were treated with hormonal therapy.ConclusionsThe incidence of DCIS has risen dramatically with the advent of screening mammography. Increasing numbers of these patients are treated with BCT, although a large proportion are still treated with mastectomy, in some cases combined with axillary dissection. Sentinel lymph node biopsy and tamoxifen are important components of therapy, the use of which is slowly increasing in the treatment of DCIS.

Use of biologic mesh for a complicated paracolostomy hernia

BACKGROUND Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. Because the traditional surgical options of primary repair with or without ostomy repositioning have led to disappointing results, the use of mesh is indicated, especially in the setting of multiple recurrences. METHODS After laparoscopic lyses of adhesions, the colostomy is pushed against the lateral abdominal wall, and a bovine pericardium graft is gently stretched and draped over the colostomy (the Sugarbaker technique). Transfascial sutures and tacks are placed along the perimeter of the mesh and around the colon to prevent small bowel herniation. RESULTS The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up, the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results. CONCLUSION Although several studies indicate the feasibility and efficacy of synthetic permanent mesh repair, the concerns of mesh infection, erosion, and ostomy obstruction still persist. The authors suggest parietalizing the bowel and using a biologic mesh.

Gallbladder cystadenoma and common bile duct obstruction.

Cystadenomas are usually found in the extra-hepatic bile ducts in conjunction with multilocular cysts in the liver. Cystadenoma of the gallbladder itself is a rare finding, cited only once in the literature as the cause of extrinsic obstruction of the common bile duct (5). In this report, we describe the endoscopic retrograde cholangiopancreaticographic (ERCP) detection of intrinsic obstruction of the cystic duct and common bile duct by such a tumor in a 47-yr-old woman.

Management of Recurrent Inguinal Hernias After Total Extraperitoneal (TEP) Herniorrhaphies

INTRODUCTION The laparoscopic repair offers clear advantages in recurrent inguinal hernias after open herniorrhaphy. Less clear is the role of laparoscopy for recurrences after previous laparoscopic inguinal herniorrhaphies. In this paper, we present our experience with both laparoscopic and open inguinal hernia repair of laparoscopic recurrences. METHODS All patients who had undergone repair of recurrences after previous laparoscopic hernia repair from July 2004 to July 2007 were included in this study. Charts were reviewed for all these patients. RESULTS Six patients were diagnosed with 7 recurrent inguinal hernias after laparoscopic repairs. All the initial laparoscopic repairs, except for one, were total preperitoneal (TEP) with the placement of lightweight polypropylene mesh. The average time from the initial repair to the diagnosis of recurrence was 20 months (range 3-84). Four of the 7 recurrences were treated with a laparoscopic approach. The other three recurrences were repaired in an open fashion as per the preoperative plan. In 2 of the laparoscopic cases, the peritoneal flap was not able to cover the mesh, so a tissue-separating mesh with fibrin sealant was utilized to cover the myopectineal orifice. No intra- or postoperative complications were recorded. There were no recurrences at an average follow-up of 14 months (range, 11-17). CONCLUSIONS Laparoscopic repair can be offered to those patients with a recurrence after a previous laparoscopic repair. Further studies comparing laparoscopic repair versus open repair of recurrences after laparoscopic inguinal hernia repair will be helpful in defining the best approach when encountering these recurrences.

A technique for emergency liver packing.

Control of liver hemorrhage may present a daunting clinical scenario. Use of liver packing techniques is highly effective to control bleeding but can result in significant recurrent bleeding with pack removal. Such bleeding is particularly a problem when large portions of the hepatic parenchymal surface and Glisson’s capsule have been disrupted. We describe, herein, our approach to hepatic packing in scenarios where a large component of hepatic capsular disruption has occurred. Use of a non-stick bowel bag is employed on the disrupted liver surface, which, when removed, will not result in liver rebleeding. This technique has been used successfully in the management of five cases of severe liver injury with extensive capsular disruption. Familiarity with such an approach may facilitate management of similar liver injuries.

Association Between American Board of Surgery In-Training Examination Scores and Resident Performance

IMPORTANCE The American Board of Surgery In-Training Examination (ABSITE) is designed to measure progress, applied medical knowledge, and clinical management; results may determine promotion and fellowship candidacy for general surgery residents. Evaluations are mandated by the Accreditation Council for Graduate Medical Education but are administered at the discretion of individual institutions and are not standardized. It is unclear whether the ABSITE and evaluations form a reasonable assessment of resident performance. OBJECTIVE To determine whether favorable evaluations are associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of preliminary and categorical residents in postgraduate years (PGYs) 1 through 5 training in a single university-based general surgery program from July 1, 2011, through June 30, 2014, who took the ABSITE. EXPOSURES Evaluation overall performance and subset evaluation performance in the following categories: patient care, technical skills, problem-based learning, interpersonal and communication skills, professionalism, systems-based practice, and medical knowledge. MAIN OUTCOMES AND MEASURES Passing the ABSITE (≥30th percentile) and ranking in the top 30% of scores at our institution. RESULTS The study population comprised residents in PGY 1 (n = 44), PGY 2 (n = 31), PGY 3 (n = 26), PGY 4 (n = 25), and PGY 5 (n = 24) during the 4-year study period (N = 150). Evaluations had less variation than the ABSITE percentile (SD = 5.06 vs 28.82, respectively). Neither annual nor subset evaluation scores were significantly associated with passing the ABSITE (n = 102; for annual evaluation, odds ratio = 0.949; 95% CI, 0.884-1.019; P = .15) or receiving a top 30% score (n = 45; for annual evaluation, odds ratio = 1.036; 95% CI, 0.964-1.113; P = .33). There was no difference in mean evaluation score between those who passed vs failed the ABSITE (mean [SD] evaluation score, 91.77 [5.10] vs 93.04 [4.80], respectively; P = .14) or between those who received a top 30% score vs those who did not (mean [SD] evaluation score, 92.78 [4.83] vs 91.92 [5.11], respectively; P = .33). There was no correlation between annual evaluation score and ABSITE percentile (r(2) = 0.014; P = .15), percentage correct unadjusted for PGY level (r(2) = 0.019; P = .09), or percentage correct adjusted for PGY level (r(2) = 0.429; P = .91). CONCLUSIONS AND RELEVANCE Favorable evaluations do not correlate with ABSITE scores, nor do they predict passing. Evaluations do not show much discriminatory ability. It is unclear whether individual resident evaluations and ABSITE scores fully assess competency in residents or allow comparisons to be made across programs. Creation of a uniform evaluation system that encompasses the necessary subjective feedback from faculty with the objective measure of the ABSITE is warranted.

Abdominal Wall Hernia in the Elderly

Abdominal wall hernia repair is the most common surgical procedure in the United States. More than 500,000 herniorrhaphies are performed annually. The incidence of groin hernias, the most common type of abdominal wall hernia, in men over age 65 is approximately 13 per 1000 population.1 The incidence in women is 12–25% that of men. In a British study of more than 30,000 inguinal hernia repairs, 27% were in an elderly population; 85.5% of these cases were elective repairs on patients age 65 or older, and the remaining 14.5% were classified as emergency procedures.2

The Automated Operating Room: A Team Approach to Patient Safety and Communication

INNOVATION IN SAFETY: SAFETY IN INNOVATION The Automated Operating Room: A Team Approach to Patient Safety and Communication For decades, high-risk industries have relied on safety checklists to limit the adverse consequences of human error.1 The checklist model has only recently been adapted in the surgical field after the World Health Organization launched the “Safe Surgery Saves Lives” campaign in 2006.2,3 Various studies4,5 have shown that the use of checklists reduces death rates and perioperative complication rates, and their use also improves teamwork and communication, potentially contributing to improved patient outcomes. On the other hand, a recent study6 from Canada showed that this tool did not reduce mortality rates or the numbers of complications, emergency department visits, and readmissions. While the use of a checklist remains a standard of care, the priority has shifted to patient safety, compliance with mandates, efficiency, and the monitoring of outcomes. These parameters are much harder to quantify. The Veterans Health Administration’s initiative to improve operating room safety and efficiency has motivated the Bruce W. Carter Department of Veterans Affairs (VA) Medical Center of the Miami VA Healthcare System to investigate a technology-enabled solution to automate safety checklists, integrate patient data, and track staff compliance with safety measures. Before the automated system, the Miami VA Healthcare System was only capable of auditing 5% of cases for checklist compliance, which is insufficient to ensure proper utilization, standardization, and accountability.

Phase II study: Neo-adjuvant chemotherapy (NAC) with fudr (F), leucovorin (L), oxaliplatin (O), and docetaxel (D) (FLOD) in chemo-naïve operable esophageal adenocarcinoma (EAC)

15503 Background: A pathological complete response (pCR) to NAC, without the use of radiation therapy (RT), has not been previously reported in operable chemo-naive stage III EAC. Toxicity profiles (TP) to FLOD are explored in this ongoing study. Methods: Patients (Pt), who had been diagnosed with operable stage III EAC, received 2 cycles of NAC. Each cycle consisted of a 30 min infusion of D (25 mg/m2), followed by F (110 mg/kg) and L (500 mg/m2) as a 24 hour infusion on Week (Wk) 1, 2 and 3. O (85 mg/m2) was infused over 2 hours on Wk 1 and 3. Wk 4 was rest. Dose reductions (DR) were allowed: 100 and 90 mg/kg for F, 20 and 15 mg/m2 for D and 65 mg/m2 only for O. NAC delays up to 2 Wk were allowed. EUS and PET/CT were performed prior and after NAC. Patients underwent surgical resection after 2 cycles of NAC. TP were graded per NCI CTCAE v. 3. The pCR rate is set as a primary endpoint. Results: 29 Pt, median age 63 (50–80), 23 males and 6 females were accrued. KPS ranged from 70 to 100. TP were: Grade 4: ...

Phase II neoadjuvant and adjuvant chemotherapy for localized esophageal carcinoma

4147 Background: Patients (Pts) with localized esophageal carcinoma were evaluated for toxicity, operative mortality/morbidity, and overall survivorship in a regimen that did NOT contain radiation therapy. METHODS Pts with T3N1M0 esophageal carcinoma confirmed by endoscopic ultrasound and CAT scan were eligible for this study. Our therapy consisted of combined Cisplatin100 mg/m2, Paclitaxel (Taxol) 125mg/ m2, Fluorodeoxyuridine (FUdR) 150 mg /Kg or 80 mg/Kg, and Leucovorin 500mg /m2. Chemotherapy was given for 16 weeks prior to surgery. Adjuvant chemotherapy was administered for the patients whose pathology at the time of the surgery demonstrated microscopic disease. RESULTS 33 pts (29 males, 4 females) with adenocarcinoma (n=30) or squamous cell carcinoma (n=3) were enrolled. 26 pts (78%) were symptomatic with dysphagia at the time of enrollment on the study. 28 pts completed two cycles of neoadjuvant chemotherapy, 19 (68%) showed improvement of dysphagia. There were 9 instances of grade 3 or 4 hematological toxicity. There were 11 instances of non-hematological grades 3-4 toxicities: fatigue (4), nausea (1) diarrhea (2) and stomatitis (4). Of 33 R0 resections, 5(15%) had no gross disease, 2 (6%) had no microscopic residual disease. Major surgical complication occurred in 5(15%) of 33 pts. Operative mortality was 1 of 33 pts. CONCLUSIONS Our regimen of preoperative and postoperative chemotherapy without radiation for esophageal carcinoma has produced a rapid relief of dysphagia, acceptable toxicity and durable response rates. No patient developed local recurrence, however, 14 pts developed distant metastasis, the sites included: 1 rectum and mediastinal lymph node, 2 brain, 2 liver and lung, 1 liver and spleen, 3 bone, 4 liver, lung, and brain, and 1 lung. Seventeen pts died after being followed for a median of 12 months (range 2 to 43 months), while 16 others remain alive with median follow up of 39 months (range 5 to 60 months). Median survival was estimated to be 42 months with a 95% lower confidence bound of 14 months. The Kaplan-Meier estimates of 1- and 3-year survival were 75% (95%CI: 60-90%) and 50% (95%CI: 32 to 68%). No significant financial relationships to disclose.