Early Postoperative Pneumothorax Might Not Be ‘True’ Recurrence

Objectives: To date, there is no consensual definition of what constitutes a postoperative recurrence of primary spontaneous pneumothorax (PSP), despite there being many studies reporting a high incidence of recurrence. This study aims to describe the long-term recurrence rates of pneumothorax and to suggest a possible way to differentiate recurrence events based on temporal patterns. Methods: This single-center study retrospectively evaluated all postoperative recurrence of PSP from January 2007 to May 2019. Patients’ demographics, history of pneumothorax, radiologic data, surgical technique, and the time between operation and recurrence were analyzed. Univariate and multivariable analyses were conducted to find potential risk factors related to long-term recurrence. Results: Of the 77 postoperative recurrent cases of pneumothorax, 21 (27.2%) occurred within 30 days after surgery and, thus, were classified as early recurrences (ER), while the remaining cases were classified as late recurrences (LR). There was no difference in preoperative variables between the two groups. However, the rate of incidence of second recurrence (SR), which represented a long-term prognosis, was significantly higher in the LR group (28.6% vs. 4.8%, p = 0.030). On univariate and multivariable analyses, late recurrence was the only significant factor predicting later recurrence events. Conclusion: Postoperative recurrence (PoR) within 30 days had a lower SR rate. Therefore, it might not be a ‘true’ postoperative recurrence with a favorable prognosis. Further studies investigating postoperative recurrence based on temporal patterns would be warranted to improve the classification of PoR.

791 RECURRENT HIATAL HERNIA A HIGH PREDICTOR OF PATHOLOGIC REFLUX AND NEED FOR REINTERVENTION

Anti-reflux surgery (ARS) has been postulated to have high failure rates, which may approach 50% depending upon hiatal hernia size. Most failures are thought to be related to wrap disruption or hiatal hernia recurrence. Recently, diaphragmatic mesh augmentation has been shown to reduce hiatal hernia recurrence. We aimed to determine factors that influence recurrence based on vigilant imaging and diagnostic pH studies, and the need for surgical reintervention. Methods A prospectively maintained database of all patients undergoing index robotic ARS (including Hill, Nissen, Toupet, and Linx procedures) with Phasix ST ® mesh was queried. Between December 2016 and July 2020, 134 patients were identified of which 92 met inclusion criteria for post-operative barium esophagram performed at routine intervals (6, 12, or 24-months) or for recurrent symptoms. Median follow-up time was 11.4 months. Clinical characteristics, manometry, pH studies, as well as surgical approach was evaluated. Radiographic recurrences were then associated with endoscopic confirmation and rates of surgical re-intervention. Results Radiographic recurrence >2 cm was noted in 9 (9.8%) patients, of which 44% were symptomatic, compared to 36% of those without radiographic recurrence (p = 0.620). Endoscopy confirmed recurrence in 67% of patients with radiographic recurrence versus 0% without (p = 0.001). When all radiographic recurrences, including those <2 cm, were evaluated, 17 (18%) were identified, of which 53% of patients were symptomatic. Endoscopic and pH studies confirmed recurrences in 75% and 71% of these patients, respectively. Overall reintervention rates were 23% in the setting of any radiographic recurrence versus 1.3% without (p = 0.001). Conclusion Recurrence rates following robotic ARS and hiatal hernia repair with mesh augmentation appear low with nearly 1-year follow-up. Prior to surgical reintervention, endoscopic and pH studies are warranted to confirm symptomatic recurrence. Recurrent hiatal hernias, including those <2 cm, can lead to abnormal pH studies that merit reintervention at rates higher than those without evidence of recurrence. Longer term follow-up is required to optimally delineate true recurrence patterns.

New Primary Vs True Recurrence In Relapsed Retroperitoneal Liposarcoma: An Analysis of Clinicopatholgical Characteristic Differences And Relapse-Free Survival

Background This study aimed to classify relapsed retroperitoneal liposarcoma (RLS) as new primary (NP) or true recurrence (TR) and to assess the implications for therapeutic management of these classifications. Methods Patients with recurrent RLS were classified as NP if the relapse was different from the former tumor’s pathology subtype and anatomical location. Kaplan-Meier curves were adapted to estimate relapse-free survival (RFS), and logistic regression analysis was used to explore the factors related to NP.Results Total 177 patients with relapsed RLS were included in this study. The median tumor sizes were 16 cm (IQR, 13-22 cm, NP) and 18 cm (IQR, 12-25 cm, TR) (P=0.003). Multifocal tumors (89.2% vs 73.8%, P=0.011) and multiple pathology subtypes (52.7% vs 31.1%, P=0.004) were more common in the NP group and tended to invade wider anatomical areas (85.1% vs 71.8%, P=0.037). The median RFS was 17 months (IQR, 7-35 months) in the NP group and 12 months (IQR, 5-23 months) in the TR group, and NP patients showed a longer RFS than TR patients (P=0.004). When the log-rank test was conducted, low-grade pathology, tumor growth rate ≤ 1.25 cm/month and tumor size ≤ 16.5 cm had a significant influence on the NP phenomenon (P=0.015, 0.019, and 0.028, respectively). Logistic regression analysis illustrated that current surgeries, pathology subtype varieties and pathology grade were independent risk factors for NP (P=0.017, 0.019, and 0.025, respectively).Conclusion NP patients have longer RFS than TR patients, and their tumors tend to have multiple pathology subtypes and tumors and are more likely to invade wider anatomical areas. This classification contributes to a better understanding of RLS and provides new evidence for different therapeutic management of relapsed tumors.

Type of recurrence, cause of death and second neoplasms among 737 patients with ductal carcinoma in situ of the breast: 15-year follow-up.

e12592 Background: The aim of the study is to assess the results of the treatment of 737 consecutive patients with DCIS with particular attention to the character of recurrences, other neoplasms and causes of deaths. Methods: A retrospective analysis was carried out of 737 consecutive DCIS patients treated in one institution in the years 1996-2011. The percentage of failures, causes of death, cumulated recurrence risk, DFS, OS depending on the method of treatment (mastectomy, breast conserving treatment BCT, breast conserving surgery BCS), was calculated. Results: 66 recurrences (42% DCIS, 58% invasive) were reported: 61 recurrences in the breast, 5 outside the breast. The comparison of mammography images before the initial treatment and after local recurrence revealed the true recurrence in the breast in 48/61 (79%) of cases. The cumulated recurrence risk after 15-year observation, after mastectomy, BCT and BCS was 3.2%, 19.5% and 31.2 %, respectively (p < 0.001). 15-year DFS after mastectomy, BCT and BCS was 72%, 65% and 48%, respectively (p < 0.001). 15-year OS after mastectomy, BCT and BCS was 75%, 83% and 70%, respectively, p = 0.329. In the course of the whole observation period 124 other neoplastic lesions in 121 patients (16%) were reported including 58 (8%) contralateral breast cancers. Deaths due to DCIS progression were reported in 4 (0.5%) of patients. An overwhelming majority (74/86) of deaths was linked to the age of the patients or other diseases, including other neoplasms. Conclusions: The highest recurrence risk reported in patients after BCS was unacceptable and, moreover, it kept growing over the fifteen years of observation. 79% of recurrences in the treated breast were true recurrences. Local recurrences were effectively treated without influence on OS. The percentage of deaths due to DCIS was low.

Recurrence of Dupuytren’s disease following surgery – an analysis of the causes and incidence

The incidence of recurrence Dupuytren’s disease after surgery is estimated up to 50% in relation to progression of the disease, treatment modality and time of the follow-up. The objective of this study was an analysis of the causes and frequency of recurrences among 67 patients following surgery for recurrent Dupuytren’s disease in the author’s institution in the years 2016–2018. The 67 patients comprised 56 men (83%) and 11 women (17%) at a mean age of 59 years (range 40–81), of which 27 patients (40%) had undergone a 2nd operation to the same hand, 22 patients (33%) had undergone a 3rd operation, 14 (21%) had undergone a 4th operation, and the remaining 4 patients had each undergone more than 5 operations on the same hand. The defined rate of recurrence in the analysed period was 20%. The mean time interval from the last operation and the appearance of signs of a relapse was 14 months; in 42 patients (63%) it was less than 1 year (3–12 months) and in the remaining 25 (37%) 1–4 years. Progressing contracture of the previously operated finger and contracture of the adjacent finger which was not involved at the 1st operation, was the most frequently observed pattern of recurrence, found in 29 patients; it was a combination of true recurrence and extension of the disease. The number of operations performed in a given patient was found to be a statistically significant risk factor of recurrence.

Invasive Cancer Confined to the Nipple of the Conserved Breast: A Case Report

Invasive breast cancer deriving from the milk duct and lobule that develops in the nipple is extremely rare, except in Paget’s disease and skin cancer. This is the second reported case of the development of invasive cancer confined to the nipple after breast-conserving surgery. A 69-year-old woman visited our department due to redness, swelling, and bloody discharge of the right nipple in the last month. A needle biopsy was suggestive of invasive ductal carcinoma; we performed a removal surgery of the right residual breast tissue and a second sentinel lymph node biopsy. She underwent these procedures 10 years previously as well. Thus, we diagnosed the present lesion as a local recurrence, but it was unknown whether the lesion was a true recurrence or second cancer, namely, metachronal ipsilateral breast cancer. The present case helps promote awareness that invasive cancer rarely develops in the nipple after conserving surgery. Patients should be encouraged to visit a medical facility if experiencing skin changes and swelling of the nipple. Additionally, breast cancer patients must be carefully selected for breast-conserving surgery; failure to do so may later result in nipple-specific local recurrence.

Recurrence of Crohn’s Disease After Small Bowel Transplantation: Fact or Fiction

Small bowel transplant is an acceptable procedure for intractable Crohn’s disease (CD). Some case reports and small series describe the apparent recurrence of CD in the transplanted bowel. This commentary discusses evidence in favor of and against this alleged recurrence and argues that a molecular characterization is needed to prove or disprove that inflammation emerging in the transplanted bowel is a true recurrence of the original CD.

Thinking About Hiatal Hernia Recurrence After Laparoscopic Repair: When Should It Be Considered a True Recurrence? A Different Point of View

Background: High rates of recurrence after laparoscopic hiatal hernia repair have been published. Most of these recurrences are asymptomatic and only diagnosed by endoscopic or radiologic studies. The definition of hiatal hernia recurrence is still under discussion. Objective: This study aimed to define a true hiatal hernia recurrence using a score and classification criteria considering the presence of symptoms and size of the recurrence. Patients and Methods: A total of 153 patients with giant hiatal hernia larger than 10 cm in diameter underwent an operation using a laparoscopic approach. Of these patients, 129 had a complete follow-up (3–5 years) after surgery, and they were the only ones included in this study. The IT system of our hospital was our database for data registration. A score and classification were designed for definition of a “true” hiatal hernia recurrence, based on postoperative symptoms and the presence or not of a hiatal hernia in both radiologic and endoscopic evaluations. Results: Hiatal hernia recurrence based on endoscopic and/or radiologic hiatal hernia was found in 55 patients (42.6%), and only 28 of them (50.9%) had recurrent symptoms. Applying the score and proposed classification, no recurrence was considered in 18 patients (13.9%). Symptomatic and true recurrence were considered in 22.9% of patients (29 patients). Reoperation was needed for 7 patients (5.4%) because of symptomatic and radiologic recurrence. Conclusions: Postoperative symptoms, endoscopic findings, or radiologic findings are important for the definition of the type of recurrence and for the indication of appropriate treatment. The proposed score and classification are useful in order to specify the hiatal hernia recurrence and treatment.

Burden between Undersupply and Overtreatment in the Care of Primary Spontaneous Pneumothorax

Background The optimal treatment of primary spontaneous pneumothorax (PSP) is still controversial. The purpose of this study was to analyze the incidence of recurrence, the recurrence-free time, and to identify risk factors for recurrence after PSP. Methods We performed a retrospective analysis of 135 patients with PSP who were treated either conservatively with a chest tube (n = 87) or surgically with video-assisted thoracoscopic surgery (VATS; n = 48) from January 2008 through December 2012. Results In this study, 101 (74.8%) male and 34 (25.2%) female patients were included with a mean age of 35.7 years. The indications for surgery included blebs/bullae in the radiological images (n = 20), persistent air leaks (n = 15), or the occupations/wishes of the patients (n = 13). A first ipsilateral recurrent pneumothorax (true recurrence) was observed in 31.1% of all patients (VATS: 6.25%, conservative: 44.8%). Including contralateral recurrence, the overall first recurrence rate was 41.3% (VATS: 14.6%, conservative: 57.5%). The recurrence-free time did not differ significantly between the treatment groups (p = 0.51), and most recurrences were observed within the first 6 months after PSP. Independent risk factors identified for the first recurrence were conservative therapy (p = 0.0001), the size of the PSP (conservative; p = 0.016), and a body mass index <17 (VATS; 0.022). The risk for second and third recurrences of PSP was 17.5 and 70%, respectively, for both treatment groups, but it was 100% after conservative therapy. Conclusion Surgery for PSP should be selected based on the risk factors and the patient's wishes to prevent first recurrences but also to avoid overtreatment. The treatment of first and subsequent PSP recurrences should be with surgery since conservative treatment is associated with a 100% recurrence rate.