Breast conservation-performed with contemporary imaging and multimodality treatment-provides excellent local control and survival for women with T0N+ breast cancer and can be safely offered instead of mastectomy.
BackgroundEarly cholecystectomy (EC) for acute cholecystitis (AC) is standard. Often patients with cancer are not EC candidates and require non-surgical treatments. We analyzed factors associated with non-surgical treatments and progression to interval cholecystectomy (IC).Materials and methodsWe performed a case–control study reviewing consults for AC from 2001 to 2017 in a tertiary cancer center. Study patients had cancer, abdominal pain, and positive imaging studies. Univariate analysis and regression modeling evaluated associations between non-surgical management, resolution of AC, and IC.Results206 patients met the criteria. 20 underwent EC, 132 took antibiotics (ABX), and were treated with 54 percutaneous cholecystostomy tubes (PCTs). AC resolution was higher with PCT versus ABX (94% vs. 80%, p=0.02). Univariate analysis revealed higher absolute neutrophil counts (ANCs) and longer length of stay in PCT, and logistic regression revealed independent associations of abdominal malignancy (OR=6.66, 95% CI 1.36 to 32.6, p=0.09), abdominal radiation (OR=0.09, 95% CI 0.02 to 0.53, p<0.01), and PCT with resolution of AC (OR=4.89, 95% CI 1.18 to 20.2, p=0.01). IC rate was 43%, and median time to IC after was 45 to 67 days. Multivariate analysis revealed nausea/vomiting and increasing platelets are independently associated with IC. Recent chemotherapy increases odds of IC in the presence of rising ANC (OR=1.14, 95% CI 1.00 to 1.30, p=0.05).ConclusionPCT has a higher success rate of resolving AC than ABX. Abdominal malignancy increases odds of resolution; abdominal radiation decreases odds. Nausea/vomiting and recent chemotherapy, coupled with rising ANC are associated with IC, but less than 50% of patients return for operation. PCT may not be a bridge to IC in our population.Level of evidence II.
Background Chemotherapy is associated with postoperative ventral incisional hernia (PVIH) after right hemicolectomy (RHC) for colon cancer, and abdominal wall closure technique may affect PVIH. We sought to identify clinical predictors of PVIH. Methods We retrospectively analyzed patients who underwent RHC for colon cancer from 2008-2018 and later developed PVIH. Time to PVIH was analyzed with Kaplan-Meier analysis, clinical predictors were identified with multivariable Cox proportional hazards modeling, and the probability of PVIH given chemotherapy and the suture technique was estimated with Bayesian analysis. Results We identified 399 patients (209 no adjuvant chemotherapy and 190 adjuvant chemotherapy), with an overall PVIH rate of 38%. The 5-year PVIH rate was 55% for adjuvant chemotherapy, compared with 38% for none (log-rank P < .05). Adjuvant chemotherapy (hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.18-2.31, P < .01), age (HR .99, 95% CI .97-1.00, P < .01), body mass index (HR 1.02, 95% CI 1.00-1.04, P < .01), and neoadjuvant chemotherapy (HR 1.92, 95% CI 1.21-3.00, P < .01) were independently associated with PVIH. Postoperative ventral incisional hernia was more common overall in patients who received adjuvant chemotherapy (46% compared with 30%, P < .01). In patients who received adjuvant chemotherapy, the probability of PVIH for incision closure with #1 running looped polydioxanone was 42%, compared with 59% for incision closure with #0 single interrupted polyglactin 910. Discussion Exposure to chemotherapy increases the probability of PVIH after RHC, and non–short stitch incision closure further increases this probability, more so than age or body mass index. The suture technique deserves further study as a modifiable factor in this high-risk population.
BACKGROUND:The expansion of robotic surgery requires identifying factors of competent robotic bedside assisting. Surgical trainees desire more robotic console time, and we hypothesized that protocolized robotic surgery bedside training could equip Advanced Practice Providers (APPs) to meet this growing need. No standardized precedent exists for training APPs.
METHODS:We designed a pilot study consisting of didactic and clinical skills. APPs completed didactic tests followed by proctored clinical skills checklists intraoperatively. Operating surgeons scored trainees with 10-point Likert scale (< 5 not confident, > 5 = confident). APPs scoring > 5 advanced to a solo practicum. Competence was defined as: didactic test score > 75 th percentile, completing < 5 checklists, scoring > 5 on the practicum. The probability of passing the practicum was calculated with Bayes theorem.
RESULTS:Of 10 APP trainees, 5 passed on initial attempt. After individualized development plans, 4 passed retesting. Differences in trainee factors were not statistically significant, but the probability of passing the practicum was < 50% if more than four checklists were needed.CONCLUSIONS: Clinical experience, not didactic knowledge, determines the probability of intraoperative competence. Increasing clinical proctoring did not result in higher probability of competence. Early identification of APPs needing individualized improvement increases the proportion of competent APPs.
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