Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

Introduction Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process. Methods All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables. Results Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis. Conclusion Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.

Timely Cancer Genetic Counseling and Testing for Young Women With Breast Cancer: Impact on Surgical Decision-making for Contralateral Risk-reducing Mastectomy

PURPOSE: Genetic testing (GT) can identify individuals with pathogenic variants (PV) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic. METHODS: Clinical data was reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated. RESULTS: Of the 194 patients, 30 (15.5%) had a PV in a BC predisposition gene (ATM , BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV carriers and 42/164 (25.6%) non-carriers. Only a positive test result was associated with CRRM (p < 0.01). For the 164 with uninformative results, CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.19), or BC stage (p = 0.10). CONCLUSION: In this cohort of young women with BC, the identification of a PV in a BC predisposition gene was the only factor associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.

Bone metastases from renal cell carcinoma: A case report and literature review

Management of bone metastases from Renal Cell Carcinoma (RCC) has significantly changed after the era of targeted therapy that improved the overall survival. This has sucked the different interveners in their management to push the surgical indications in order to improve outcome and quality of life for these patients. In case of a solitary metastasis or a limited number of resectable metastases wide resections have to be considered according to patient profile, comorbidities, localization, heaviness of the surgery and to benefit –risk balance. However such surgeries are highly demanding procedures that must be carefully planned and discussed in multidisciplinary team and with patient. Thus, surgical decision-making for a second metastasis and according to what criteria remains a subject of controversy. We report a case of an aggressive metastatic renal cell carcinoma with good functional and oncologic outcomes 3 years after surgery coupled with anti-angiogenic treatment. A review of the literature concerning recent attitudes in the management of bony metastatic renal carcinoma was carried out. Keywords: renal cell carcinoma; bone metastases; surgery; targeted therapy.

Validation of an Online Calculator to Predict Short-term Postoperative Outcomes in Patients with Metastatic Brain Tumors

Introduction: Estimating the risk of extended length of stay (LOS) or non-routine discharge disposition is helpful in surgical decision-making for patients with brain metastases (BM). In 2020, an online calculator was introduced by Khalafallah et al. that stratified the risk of patients with brain tumors based on poor surgical outcomes. We applied the calculator to our population of BM patients to determine its generalizability and validity. Methods: We included BM patients who underwent a cranial procedure between 2015 and 2018 at a single academic institution. Patient age, race, marital status, admission status, KPS score, and medical co-morbidities (5-point modified frailty index (mFI-5)) were included in the analysis. We calculated the areas under the Receiver Operating Characteristics (ROC) curves to determine the validity of the model proposed in predicting extended LOS (>7 days) and need for specialty care at discharge (non-routine discharge disposition). Results: We analyzed 244 patients (mean age 61.2 years (SD 11.1), 57.0% female, and 78.1% Caucasian). The areas under the ROC curves were 0.8427 and 0.8422 for extended LOS and non-routine discharge disposition, suggesting high accuracy of the models for these outcomes. However, the (mFI-5) was not a significant predictor of either outcome in our multivariate analyses. Conclusions: We validated Khalafallah et al.’s predictive models of extended LOS and non-routine discharge disposition in our patient population, which included a broader range of surgical procedures. Further investigation of this model could clarify how the type of neurosurgical procedure influences outcomes, the role of the mFI-5, and its overall generalizability.

Communicating imaging findings in peritoneal mesothelioma: the impact of ‘PAUSE’ on surgical decision-making

The peritoneal cavity is the second commonest site of mesothelioma after the pleural cavity. There are five histological types of peritoneal mesothelioma with variable symptomatology, clinical presentation and prognosis. Cystic mesothelioma is a borderline malignant neoplasm with a favourable prognosis, well-differentiated papillary mesothelioma is generally a low-grade malignancy, and all other varieties such as epithelioid, sarcomatoid and biphasic mesothelioma are highly malignant types of peritoneal mesothelioma with poor prognosis. Malignant peritoneal mesothelioma was considered inevitably fatal prior to the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in selected cases where long-term survival and cure could be achieved. However, the survival benefits following CRS and HIPEC mainly depend on completeness of cytoreduction, which come at the cost of high morbidity and potential mortality. Using the acronym ‘PAUSE’, we aimed at describing the key imaging findings that impact surgical decision-making in patients with peritoneal mesothelioma. PAUSE stands for peritoneal cancer index, ascites and abdominal wall disease, unfavourable sites of involvement, small bowel and mesenteric disease and extraperitoneal disease. Reporting components of ‘PAUSE’ is crucial for patient selection. Despite limitations of CT in accurately depicting the volume of disease, describing findings in terms of PAUSE plays an important role in excluding patients who might not benefit from CRS and HIPEC.

Resection or Preservation? A Tough Surgical Decision for Chinese Breast Cancer Patients Who are in Line with Breast Conserving

Purpose Breast cancer patients who are in line with breast conserving are faced more challenges in making surgery decision, because breast conservation and mastectomy have equivalent oncologic outcomes. The purpose of this study is to analyze the surgical decision-making process for breast cancer patients and further explore the reasons why do Chinese women who are in line with breast conserving are more likely to choose mastectomy. Methods A qualitative study was conducted. With the sample saturation principle, data collected by semi-structured interviews with 24 breast cancer patients who are in line with breast conserving. Colaizzi’s method of phenomenology was used for data analysis. Results Three major themes emerged from the data. The themes were the following: (1) lack of significant decision-making support (stereotyping of breast cancer surgery, inferior quality of interaction with health professions, and without the help of decision aids); (2) can’t mull under the strike (immediacy of the decision, breasts are out of deliberating, and escape); and (3) edified by the Chinese culture (deep family values, hiding concerns about femininity, and conservative character). Conclusions Our findings explore the reasons why more Chinese breast cancer patients with breast conserving conditions choose mastectomy, and help patients to choose knowledge-based treatment options which are concordant with their needs, values, and preferences.