Purpose of Review Obtaining negative margins in breast conservation surgery continues to be a challenge. Re-excisions are difficult for patients and expensive for the health systems. This paper reviews the literature on current strategies and intraoperative clinical trials to reduce positive margin rates. Recent Findings The best available data demonstrate that intraoperative imaging with ultrasound, intraoperative pathologic assessment such as frozen section, and cavity margins have been the most successful intraoperative strategies to reduce positive margins. Emerging technologies such as optical coherence tomography and fluorescent imaging need further study but may be important adjuncts. Summary There are several proven strategies to reduce positive margin rates to < 10%. Surgeons should utilize best available resources within their institutions to produce the best outcomes for their patients.

Background Calculation of intracranial volume from neuroimaging can be complex and time consuming. In the adult population, there is evidence suggesting that owing to its strong correlation, head circumference (HC) may be used as a surrogate for intracranial volume (ICV). We were interested in studying the correlation between HC and ICV in patients with craniosynostosis. Methods After institutional review board approval, a retrospective review was performed on patients with craniosynostosis. GE Healthcare AdW 4.3 volume assessment software was used to calculate ICV and HC based on preoperative computed tomographic scans. Pearson correlation was used to estimate correlation coefficients between ICV and HC for this patient population, with 0 to 0.3 considered a weak correlation, 0.4 to 0.6 considered a moderate correlation, 0.7 to 1 considered a strong correlation, and P < 0.05 was considered statistically significant. Results A total of 196 craniosynostosis patients were included in this study. There were 121 male and 75 female patients. Seventy-nine patients had metopic, 45 had coronal, 64 had sagittal, and 8 had lambdoid synostosis. Mean age was 8.2 months. Mean HC and ICV were 42.9 cm and 829 cm3, respectively. Overall, there was a strong correlation between HC and ICV (r = 0.81). Patients were further categorized by craniosynostosis type. Very strong correlation was obtained for patients with coronal (0.89), metopic (0.98), and lambdoid craniosynostosis (0.97). Strong correlation was obtained for patients with sagittal synostosis (0.73). When categorized by sex, a stronger correlation was obtained for female patients (0.84) compared with male patients (0.80). Statistical significance was reached for all reported correlations. Conclusion Our preliminary data suggest that a very strong correlation exists between HC and ICV for male and female patients with all types of craniosynostosis, making HC a useful surrogate for ICV in this patient population.

Extrahepatic biliary neuroendocrine tumors (EBNETs) are extremely rare and difficult to diagnose. The vast majority are diagnosed postoperatively on histological evaluation of surgical specimens. Workup and treatment principles are largely based on retrospective series and case reports. Complete surgical resection is the gold standard treatment for these lesions. Here we present a case of a 77-year-old male with a biopsy-proven EBNET incidentally discovered during evaluation for fatty liver disease. Further workup did not show any other suspicious lesions. Resection of the tumor and multiple Roux-en-Y hepaticojejunostomy was performed. Final pathology revealed grade 1, well-differentiated neuroendocrine tumor. This is the third case reported in the literature with a confirmed preoperative EBNET diagnosis based on endoscopic biopsy results. This case highlights the feasibility of preoperative diagnosis of EBNETs and emphasizes the importance of complete surgical resection.

Objective: Type II endoleaks (TIIELs) are the most common complication after endovascular aneurysm repair (EVAR) with a reported occurrence rate ranging from 8% to 45%. However, their clinical significance is still a matter of debate. Treatment policies have varied from conservative management to angiographic evaluation and intervention. With most TIIELs managed conservatively, the question remains whether persistent collateral sac reperfusion increases the risk of reintervention, morbidity, or mortality. We assessed the effect of early TIIELs on the midterm outcomes after EVAR.Methods: We identified all patients who had undergone EVAR between January 2010 and December 2016 in the Vascular Implant Surveillance and Interventional Outcomes Network. The patients were divided into two groups: those with no TIIEL and those with a TIIEL at 30 days of follow-up. The 2-year outcomes included freedom from reintervention for type I/III endoleak, freedom from abdominal aortic aneurysm (AAA)related reinterventions, freedom from rupture, and all-cause mortality. Cox regression analysis was used to evaluate the association between TIIELs and outcomes.Results: A total of 12,728 patients had undergone EVAR during the study period, of whom, 1088 (8.5%) had developed an early TIIEL. The patients with TIIEL were older (mean age, 77 6 7 years vs 75 6 7 years; P < .001) and less likely to have a history of smoking (79% vs 82.6%; P < .001). The 2-year freedom from reintervention for type I/III endoleak estimate was 97% for the TIIEL group and 99.2% for the no TIIEL group (P < .001). The TIIEL group showed significantly lower rates of freedom from AAA-related reinterventions (92.1% vs 94%; P ¼ .02) and from rupture (95.1% vs 96.2%; P ¼ .05) at 2 years. No difference was found in the freedom from all-cause mortality between the two groups (TIIEL, 95.5%; vs no TIIEL, 94.5%; P ¼ .19). After adjustment, early TIIEL was associated with a 3.3-fold increase in reintervention for type I/III endoleaks (adjusted hazard ratio [aHR], 3.37; 95% confidence interval [CI], 2.13-5.34; P < .001), a 28% increase in AAA-related reinterventions (aHR, 1.28; 95% CI, 1.01-1.6; P ¼ .03), and a 38% increase in aneurysm rupture (aHR, 1.38; 95% CI, 1.03-1.84).Conclusions: Our study has highlighted the adverse outcomes associated with early TIIELs. These findings suggest that TIIELs are not benign and can lead to high-pressure endoleaks and even post-EVAR rupture.