Sentinel lymph node surgery after neoadjuvant chemotherapy in node-positive breast cancer

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Cavalcante FP, Millen EC, Zerwes FP, Novita GG. Role of Axillary Surgery After Neoadjuvant Chemotherapy. JCO Glob Oncol. 2020 Feb;6:238-241.

“In a US study, associating selective localization and removal of clipped nodes with SLN dissection, known as targeted axillary dissection, reduced false-negative rates to approximately 2% compared with 4% with removal of the clipped lymph node alone. [20] However, patients are required to undergo two procedures: placement of the clip before systemic treatment and marking it to identify the lymph node during surgery. A retrospective analysis showed that in patients with clipped lymph nodes who were referred for preoperative marking, the clip failed to be identified in 20% of those patients, even when computed tomography was used, with the additional risk of the clip not being removed during surgery. [21] Therefore, the use of clips is controversial, because it is sometimes impossible to remove the clip alone. Despite the association between the number of lymph nodes and false-negative rates, there are still no convincing data regarding clinical outcome.”

Caudle AS, Yang WT, Krishnamurthy S, et al. Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection. J Clin Oncol. 2016 Apr 1;34(10):1072-8.

Results: Of 208 patients enrolled in this study, 191 underwent ALND, with residual disease identified in 120 (63%). The clipped node revealed metastases in 115 patients, resulting in an FNR of 4.2% (95% CI, 1.4 to 9.5) for the clipped node. In patients undergoing SLND and ALND (n = 118), the FNR was 10.1% (95% CI, 4.2 to 19.8), which included seven false-negative events in 69 patients with residual disease. Adding evaluation of the clipped node reduced the FNR to 1.4% (95% CI, 0.03 to 7.3; P = .03). The clipped node was not retrieved as an SLN in 23% (31 of 134) of patients, including six with negative SLNs but metastasis in the clipped node. TAD followed by ALND was performed in 85 patients, with an FNR of 2.0% (1 of 50; 95% CI, 0.05 to 10.7).

Conclusion: Marking nodes with biopsy-confirmed metastatic disease allows for selective removal and improves pathologic evaluation for residual nodal disease after chemotherapy.

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Total neoadjuvant therapy in rectal cancer

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Petrelli F, et al. Total Neoadjuvant Therapy in Rectal Cancer: A Systematic Review and Meta-analysis of Treatment Outcomes. Ann Surg. 2020 Mar;271(3):440-448.

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Results: A total of 28 studies (3 retrospective and 25 prospective for a total of 3579 patients) were included in the final analysis (n = 2688 treated with TNT and n = 891 with neoadjuvant chemoradiotherapy therapy). The pooled pCR rate was 22.4% (95% CI 19.4%-25.7%) in all patients treated with TNT (n = 27 studies with data available). In n = 10 comparative studies with data available, TNT was found to increase the odds of pCR by 39% (1.40, 95% CI 1.08-1.81, P = 0.01).

Conclusions: The addition of induction or consolidation chemotherapy to standard neoadjuvant chemoradiotherapy results in a higher pCR rate. Given that the comparative analysis was derived from few randomized publications, large confirmatory trials should be carried out before a strong recommendation is made in favor of TNT.

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Article of interest: The Landmark Series: MSLT-1, MSLT-2 and DeCOG (Management of Lymph Nodes)

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Bello DM, Faries MB. The Landmark Series: MSLT-1, MSLT-2 and DeCOG (Management of Lymph Nodes). Ann Surg Oncol. 2020 Jan;27(1):15-21.

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Management of regional lymph nodes in patients with melanoma has evolved significantly in recent years. The value of nodal intervention, long utilized for its perceived therapeutic benefit, has now shifted to that of a critical prognostic procedure used to guide clinical decision making. This review focuses on the three landmark, randomized controlled trials evaluating the role of surgery for regional lymph nodes in melanoma: Multicenter Selective Lymphadenectomy Trial I (MSLT-I), German Dermatologic Cooperative Oncology Group-Selective Lymphadenectomy Trial (DeCOG-SLT), and Multicenter Selective Lymphadenectomy Trial II (MSLT-II).

Clinical Practice Guidelines: The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids

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Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018 Mar;61(3):284-292.

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“Symptoms related to hemorrhoids are very common in the Western hemisphere and other industrialized societies. Although published estimates of prevalence are varied,1,2 it represents one of the most common medical and surgical disease processes encountered in the United States, resulting in >2.2-million outpatient evaluations per year.3 A large number of diverse symptoms may be, correctly or incorrectly, attributed to hemorrhoids by both patients and referring physicians. As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the anorectal symptom and to have a clear understanding of the evaluation and management of this disease process.These guidelines address both diagnostic and therapeutic modalities in the management of hemorrhoidal disease.”

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Article of interest: Efficacy of harmonic focus scalpel in seroma prevention after axillary clearance.

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Selvendran S, Cheluvappa R, Tr Ng VK, Yarrow S, Pang TC, Segara D, Soon P. Efficacy of harmonic focus scalpel in seroma prevention after axillary clearance. Int J Surg. 2016 Jun;30:116-20. doi: 10.1016/j.ijsu.2016.04.041.

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“To summarise the salient findings of this retrospective study; we did not find a lower rate of seroma formation (as previously reported) when HF was used in ALND, instead of CD. Instead, we found increased seroma volume in patients after mastectomy and ALND compared to WLE and ALND or ALND alone. Our study had the second highest number of subjects examining HF and CD with respect to ALND.” (p. 119)

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Article of interest: Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons’ enemies

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Duconseil P, Turrini O, Ewald J, et al. Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons’ enemies. World J Surg. 2014 Nov;38(11):2946-51.

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Results: Thirty patients experienced a BC: 13 BLs (3.3 %) and 17 BSs (4.3 %). A thin bile duct (<5 mm), measured during surgery, was the only predisposing factor for developing a BL or a BS. The management of the BLs consisted of surveillance in six patients (46 %), percutaneous drainage of bilioma in four patients (31 %), and reintervention in three patients (23 %). No patient with a BS had surgery as the frontline treatment: the initial management consisted of an endoscopic procedure, a percutaneous procedure, or medical treatment. Four patients (23.5 %) underwent surgical treatment after failure of nonsurgical procedures.

Conclusions: The only identified predictive factor of BC, either a BS or a BL, was a thin bile duct. Although the noninvasive technique was the treatment of choice initially, reintervention was required in almost 25 % of the cases.

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Characterization of ischemic colitis associated with myocardial infarction

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Cappell MS, Mahajan D, Kurupath V. Characterization of ischemic colitis associated with myocardial infarction: an analysis of 23 patients. Am J Med. 2006 Jun;119(6): 527.e1-9.

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Results: Of 17,500 patients admitted to the study sites with MI, 23 (0.13%) had IC. Study patients had a high in-hospital mortality of 39%. An Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than 15 was a significant predictor of mortality in these patients (P<.04). Compared with the IC-controls, study patients had a significantly lower mean arterial pressure (MAP) (76.0 +/- 17.1 mm Hg vs 98.3 +/- 18.6 mm Hg, P<.0001) and a significantly higher rate of hypotension (57% vs 9%, odds ratio [OR] = 12.6, confidence interval [CI]: 3.10-49.7, P<.001). The 2 groups, however, had a similar mean number of risk factors for thromboembolism per patient. Study patients had more severe illness than IC-controls, as demonstrated by mean APACHE II scores (19.0 +/- 5.5 vs 10.4 +/- 4.8, P<.0001). Study patients had a significantly higher incidence of complications, including respiratory failure (57% vs 13%, P=.001), altered mental status (48% vs 13%, P<.01), and renal insufficiency or failure (61% vs 28%, P<.04). Study patients had a significantly lower minimum hematocrit. Study patients had a significantly higher rate of prolonged hospitalization (>30 days) or in-hospital death (74% vs 19%, OR = 12.3, CI: 3.47-43.5, P<.0001). Compared with MI-control patients, study patients had a significantly lower MAP, significantly higher rate of hypotension, much higher mean APACHE II score, much higher incidence of complications, and significantly worse hospital outcome.

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Sphincter of Oddi dysfunction

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Crittenden JP, Dattilo JB. Sphincter of Oddi Dysfunction. 2021 Feb 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.

The patient’s presentation, in combination with the results of their examination, should be used to stratify them to into three classes of sphincter of Oddi dysfunction. Specific diagnostic criteria for SOD include:

  • Transaminitis (greater 2 times the upper limit of normal on 2 or more occasions)
  • Common bile duct dilation (greater than 10 mm on US; greater than 12 mm on ERCP)
  • Biliary pain

Utilizing these criteria, patients are classified as follows:

Type I SOD: all three
Type II SOD: biliary pain and one of the other two criteria.
Type III SOD: biliary pain only [3]

The results of this classification will impact the subsequent treatment plan.

Sphincter of Oddi Dysfunction, gallbladder, common bile duct, main pancreatic duct, accessory pancreatic duct, mini papilla, major papilla, Ampulla of Vater, main pancreatic duct. StatPearls Publishing Illustration
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Pancreaticoduodenectomy with and without routine intraperitoneal drainage

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Van Buren G 2nd, Bloomston M, Hughes SJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014 Apr;259(4):605-12.

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Results: There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage.

Conclusions: This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.

See also: Van Buren G 2nd, Fisher WE. Pancreaticoduodenectomy Without Drains: Interpretation of the Evidence. Ann Surg. 2016 Feb;263(2):e20-1.

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Klebsiella pneumoniae liver abscess

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Jun JB. Klebsiella pneumoniae Liver Abscess. Infect Chemother. 2018 Sep;50(3):210-218. doi: 10.3947/ic.2018.50.3.210.

Abstract: Since the mid 1980s, the prevalence of liver abscess caused by hypervirulent Klebsiella pneumoniae strain has increased in Asia, particularly in Taiwan and Korea. This strain is mostly K1 or K2 serotype, and has hypercapsular and hypermucoid phenotypes. Most infections are community acquired, and patients rarely have a hepatobiliary disease prior to infection. Clinical manifestations are characterized by fever and high C-reactive protein, and metastatic infections, such as septic emboli in the lung and endophthalmitis and meningitis are frequently observed. Antibiotic resistance is rare. Antibiotic treatment and abscess drainage are needed, and early diagnosis and treatment of endophthalmitis is also important.

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