Objective assessment of aesthetic outcome after breast conserving therapy: subjective third party panel rating and objective BCCT.core software evaluation

We analysed intra- and inter-rater agreement of subjective third party assessment and agreement with a semi-automated objective software evaluation tool (BCCT.core). We presented standardized photographs of 50 patients, taken shortly and one year after surgery to a panel of five breast surgeons, six breast nurses, seven members of a breast cancer support group, five medical and seven non-medical students. In two turns they rated aesthetic outcome on a four point scale. Moreover the same photographs were evaluated by the BCCT.core software. Intra-rater agreement in the panel members was moderate to substantial (k = 0.4-0.5; wk = 0.6-0.7; according to different subgroups and times of assessment). In contrast inter-rater agreement was only slight to fair (mk = 0.1-0.3). Agreement between the panel participants and the software was fair (wk = 0.24-0.45). Subjective third party assessment only fairly agree with objective BCCT.core evaluation just as third party participants do not agree well among each other.     

Aesthetics in Breast Conserving Therapy: Do Objectively Measured Results Match Patients’ Evaluations?

Background

To analyze the relationship of objective and subjective evaluation tools of breast aesthetics, we compare the results of the BCCT.core (breast cancer conservative treatment.cosmetic results) software, a semiautomated objective symmetry evaluation tool, with those of the Aesthetic Status of the BCTOS (Breast Cancer Treatment Outcome Scale) patient questionnaire.

Materials and Methods

We included 128 patients with one-sided, primary breast cancer, treated conservatively in a prospective, exploratory study in order to assess the inter-rater reliability of the BCCT.core and the agreement between the BCCT.core and the BCTOS preoperatively, shortly and 1 year after surgery. Therefore, we use agreement rates, multiple (mk), and weighted (wk) kappa coefficients as statistical methods. Furthermore, we analyzed patient-, tumor-, and therapy-related variables as possible covariates to explain agreement.

Results

The inter-rater reliability for the semiautomated BCCT.core is very good with agreement rates up to 84% (mk = 0.80). The agreement rates of the BCCT.core and the BCTOS Aesthetic Status range between 35 and 44% subject to the different times of assessment (wk = 0.34 at best). Moreover, the patients judge their aesthetic outcome more positively than the software. None of the considered patient-, tumor-, and therapy-related covariates turned out to explain agreement.

Conclusion

The BCCT.core is a reliable instrument that shows fair agreement with patient’s perspective.     

Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer

Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, male and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k=0.24, wk=0.37) and remained within the same range (k=0.20-0.31, wk=0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.     

The value of 3D images in the aesthetic evaluation of breast cancer conservative treatment. Results from a prospective multicentric clinical trial

PurposeBCCT.core (Breast Cancer Conservative Treatment. cosmetic results) is a software created for the objective evaluation of aesthetic result of breast cancer conservative treatment using a single patient frontal photography. The lack of volume information has been one criticism, as the use of 3D information might improve accuracy in aesthetic evaluation. In this study, we have evaluated the added value of 3D information to two methods of aesthetic evaluation: a panel of experts; and an augmented version of the computational model - BCCT.core3d.Material and methodsWithin the scope of EU Seventh Framework Programme Project PICTURE, 2D and 3D images from 106 patients from three clinical centres were evaluated by a panel of 17 experts and the BCCT.core. Agreement between all methods was calculated using the kappa (K) and weighted kappa (wK) statistics.ResultsSubjective agreement between 2D and 3D individual evaluation was fair to moderate. The agreement between the expert classification and the BCCT.core software with both 2D and 3D features was also fair to moderate.ConclusionsThe inclusion of 3D images did not add significant information to the aesthetic evaluation either by the panel or the software. Evaluation of aesthetic outcome can be performed using of the BCCT.core software, with a single frontal image.     

Evaluation of cosmetic outcome following breast‐conserving therapy in trials: panel versus digitalized analysis and the role of PROMs

Cosmetic outcome is an important quality of life‐related end point following breast‐conserving therapy (BCT). To advise on a gold standard, we compare cosmetic outcome evaluated by panel and an objective evaluation (BCCT.core software). Second, patient‐reported outcome measures (PROMs) are compared to cosmetic outcome evaluation by panel and BCCT.core. Sixty‐eight breast cancer patients were included following BCT between 2007 and 2012. Two independent 6‐member panels and two observers using the BCCT.core evaluated cosmetic outcome. First, reproducibility, repeatability, and relatedness of panel and BCCT.core were analyzed using the interclass correlation coefficient (ICC). Second, the association between panel/BCCT.core with PROMs (EORTC‐QLQ‐C30/BR23, EQ‐5D‐5L, and BREAST‐Q) was analyzed with a linear regression and the goodness of fit by the R². Both panel and BCCT.core evaluations showed “excellent” intraobserver agreement (ICC 0.93 [95% CI: 0.83; 0.97] and 0.93 [95% CI: 0.84; 0.97]) for respectively panel 1 and BCCT.core 1 and “excellent” interobserver agreement (ICC 0.94 [95% CI: 0.90; 0.96] and 0.85 [95% CI: 0.77; 0.91]) respectively for panel and BCCT.core. Association between panel and BCCT.core varied, ICC 0.59‐0.69. Only the PROM BREAST‐Q showed a significant association with both panel evaluations and BCCT.core observers (panel 1 and BCCT.core 1; R² of .157 [P = .002] and .178 [P = .001]). Both panel and BCCT.core showed comparable “excellent” intraobserver and interobserver agreement. For future trials evaluating cosmetic outcome following BCT, one of those can be chosen. Solely, the PROM BREAST‐Q showed a significant association with panel and/or BCCT.core evaluation. To enable standardized cosmetic outcome evaluation and corresponding patient satisfaction in future trials, at least the BREAST‐Q should be combined with a panel or BCCT.core evaluation.     

BCCT.core - can a computer program be used for the assessment of aesthetic outcome after breast reconstructive surgery?

Aesthetic outcome is as an important endpoint of breast cancer treatment and is associated with better psychological recovery and improved quality of life. Researchers in Portugal have developed a computerised program, BCCT.core, to objectively assess aesthetic outcome of conservation breast treatment photographs. This study aimed to investigate the correlation between the Harris Scale and the BCCT.core program in patients who have undergone mastectomy and reconstruction for breast cancer. 67 cases were assessed by five independent assessors using the Harris Scale and compared with BCCT.core software. Correlation between BCCT.core and the Harris Scale was significant for all cases (r = 0.66, p < 0.01, n = 67), unilateral cases (r = 0.70, p < 0.01, n = 50), implant reconstruction cases (r = 0.72 p < 0.01, n = 28) and latissimus dorsi flap reconstruction cases (r = 0.74, p < 0.01, n = 23). BCCT.core demonstrated correlation with the Harris Scale for measuring aesthetic outcome for unilateral surgery and suggests potential use for BCCT.core to measure aesthetics for breast reconstruction after mastectomy.     

Nipple malposition after bilateral nipple‐sparing mastectomy with implant‐based reconstruction: Objective postoperative analysis utilizing BCCT.core computer software

Nipple‐sparing mastectomies (NSMs) are accepted as safe oncologic procedures for select patient populations, but objective evaluation of aesthetic outcomes has not been clearly established. The purpose of this study was to utilize BCCT.core computer software to objectively evaluate NAC malposition following bilateral NSM with implant reconstruction and compare the analysis to an expert panel. Postoperative photographs of 43 patients who underwent bilateral NSM were analyzed with the BCCT.core and by an expert panel of plastic surgery residents and attendings. The panel was asked to only evaluate nipple asymmetry and position. The intraclass correlation coefficient (ICC) was used to determine interrater reliability (n = 12) and between expert panel ratings and BCCT.core ratings. Statistics were performed using SPSS statistical package version 24.0. The ICC for the expert panel interrater reliability was excellent (ICC = 0.941, 95% CI: 0.912‐0.964). The analysis between BCCT.core individual parameters, specifically the breast retraction assessment (ie, BRA score = the difference in nipple position between the two breasts assessing breast symmetry) and expert panel, showed statistically significant positive correlation. The parameters provided by the BCCT.core software were correlated with both the mean expert panel rating and BCCT.core ratings. Therefore, it is plausible that BCCT.core parameters could be used to objectively quantify NAC malposition/asymmetry and guide treatment in patients undergoing bilateral NSM with implant reconstruction.     

Objective breast symmetry evaluation using 3-D surface imaging

This study develops an objective breast symmetry evaluation using 3-D surface imaging (Konica-Minolta V910^® scanner) by superimposing the mirrored left breast over the right and objectively determining the mean 3-D contour difference between the 2 breast surfaces. 3 observers analyzed the evaluation protocol precision using 2 dummy models (n = 60), 10 test subjects (n = 300), clinically tested it on 30 patients (n = 900) and compared it to established 2-D measurements on 23 breast reconstructive patients using the BCCT.core software (n = 690). Mean 3-D evaluation precision, expressed as the coefficient of variation (VC), was 3.54 ± 0.18 for all human subjects without significant intra- and inter-observer differences (p > 0.05). The 3-D breast symmetry evaluation is observer independent, significantly more precise (p < 0.001) than the BCCT.core software (VC = 6.92 ± 0.88) and may play a part in an objective surgical outcome analysis after incorporation into clinical practice.     

Factors determining esthetic outcome after breast cancer conservative treatment

The aim of this study was to evaluate the factors that determine esthetic outcome after breast cancer conservative treatment, based on a consensual classification obtained with an international consensus panel. Photographs were taken from 120 women submitted to conservative unilateral breast cancer surgery (with or without axillary surgery) and radiotherapy. The images were sent to a panel of observers from 13 different countries and consensus on the classification of esthetic result (recorded as excellent, good, fair or poor) was obtained in 113 cases by means of a Delphi method. For each patient, data were collected retrospectively regarding patient characteristics, tumor, and treatment factors. Univariate and multivariate analysis were used to evaluate the correlation between these factors and overall cosmetic results. On univariate analysis, younger and thinner patients as well as patients with lower body mass index (BMI) and premenopausal status obtained better cosmetic results. In the group of tumor- and treatment-related factors, larger removed specimens, clearly visible scars, the use of chemotherapy and longer follow-up period were associated with less satisfactory results. On multivariate analysis, only BMI and scar visibility maintained a significant association with cosmesis. BMI and scar visibility are the only factors significantly associated with cosmetic results of breast cancer conservative treatment, as evaluated by an international consensus panel.     

Colour evaluation in scars: tristimulus colorimeter, narrow-band simple reflectance meter or subjective evaluation?

The evaluation of scar colour is, at present, usually limited to an assessment according to a scar assessment scale. Although useful, these assessment scales only evaluate subjectively the degree of scar colour. In this study, the reliability of the subjective assessment of scar colour by observers is compared to the reliability of the measurements of two objective colour measurement instruments. Four independent observers subjectively assessed the vascularisation and pigmentation of 49 scar areas in 20 patients. The degree of vascularisation and pigmentation was scored according to a scale ranging from '1', when it appeared to be like healthy skin, to '10', which corresponds to the worst imaginable outcome of vascularisation or pigmentation. The observers also scored the pigmentation categories of the scar (hypopigmention, hyperpigmention or mixed pigmentation). Finally, each observer measured the scar areas with a tristimulus colorimeter (Minolta Chromameter) and a narrow-band simple reflectance meter (DermaSpectrometer). A single observer could reliably carry out measurements of the DermaSpectrometer and the Minolta Chromameter for the evaluation of scar colour (r = 0.72). The vascularisation of scars could also be assessed reliably with a single observer (r = 0.76) whereas for a reliable assessment of pigmentation at least three observers were necessary (r > or = 0.77). The agreement between the observers for the pigmentation categories also turned out to be unacceptably low (k = 0.349). This study shows that an overall evaluation of scar colour with the DermaSpectrometer and the Minolta Chromameter is more reliable than the evaluation of scar colour with observers. Of both instruments for measuring scar colour, we prefer, because of its feasibility, the DermaSpectrometer.     

The use of a breast symmetry index for objective evaluation of breast cosmesis

The cosmetic result after breast surgery is an important marker in clinical studies. Most authors used subjective scales to judge breast cosmesis. However, inter-observer discrepancies are very high and the use of such subjective scales for prospective trials is highly disputed. In this study we present for the first time a new invented breast symmetry index (BSI). This BSI is calculated by subtracting the size and the shape between both breasts (frontal view and side view). The BSI is measured with a software system called breast analysing tool (BAT) from digital photographs. The photographs of 27 patients have been analysed with this software by different physicians to evolve inter-observer reproducibility. The Harris scale for subjective cosmetic analyses has been correlated with the BSI. In our study the inter-observer reproducibility was excellent (Pearson correlation r=0.9; p<0.05) and the BSI was able to significantly differentiate between good and bad cosmesis (BSI values from 0%d to 30%d is good, BSI>30%d is bad cosmesis). Thus the BSI may be used for clinical studies.     

Comparison of the Reliability of Three Scoring Systems Used to Decide Whether to Apply Cement in Hip Arthroplasty Among Fracture Patients and the Effect of Surgical Experience: The Spotorno,Dorr, and Canal Flare Indices

BackgroundNo consensus has been reached regarding the best index to decide whether to use cement during hip replacement surgery. Therefore, this study compared the reliability of three frequently used scoring systems. The secondary purpose was to evaluate the effect of surgical experience on the decision to use cement.MethodsAnteroposterior radiographs of 60 hips were assessed by four orthopedic surgeons and four orthopedic residents. The observers were asked to make measurements using the Spotorno criteria, the Dorr index, and the canal flare index, and to decide whether to use a cemented or cementless femoral stem. The same X-rays were sent to all participants, in a different order, 4 weeks later, for a second evaluation. The SPSS software (version 24.0) was used for the statistical analysis. Intraobserver agreement was determined for all observers via the intraclass correlation coefficient (ICC), and interobserver reliability was calculated using the weighted kappa (κ) statistic.ResultsThe average age of the patients were 73.1 ± 12.1 years. Thirty-three (55%) patients were female and thirty-two (53.3%) had fractures on the right side. Intraobserver agreement was “excellent” for all participants according to the Spotorno criteria. The canal flare index had the lowest intra-observer agreement. The highest interobserver agreement was found using the Spotorno criteria.ConclusionThe intra- and interobserver reliabilities of the Spotorno criteria were higher than those of the Dorr index and the canal flare index. The Spotorno criteria was more useful for deciding between cemented and un-cemented hip arthroplasty.     

The acetabulum in Perthes’ disease: Inter-observer agreement and reliability of radiographic measurements

Background and purpose — Perthes’ disease leads to radiographic changes in both the femoral head and the acetabulum. We investigated the inter-observer agreement and reliability of 4 radiographic measurements assessing the acetabular changes.

Patients and methods — We included 123 children with unilateral involvement, femoral head necrosis of more than 50%, and age at diagnosis of 6 years or older. Radiographs were taken at onset, and 1 year and 5 years after diagnosis. Sharp’s angle, acetabular depth-width ratio (ADR), lateral acetabular inclination (LAI), and acetabular retroversion (ischial spine sign, ISS) were measured by 3 observers. Before measuring, 2 of the observers had a consensus meeting.

Results — We found good agreement and moderate to excellent reliability for Sharp’s angle for all observers (intra-class correlation coefficient (ICC) > 0.80 with consensus, ICC = 0.46–0.57 without consensus). There was good agreement and substantial reliability for ADR between the observers who had had a consensus meeting (ICC = 0.62–0.89). Low levels of agreement and poor reliability were found for observers who had not had a consensus meeting. LAI showed fair agreement throughout the course of the disease (kappa = 0.28–0.52). The agreement between observations for ISS ranged from fair to good (kappa = 0.20–0.76).

Interpretation — Sharp’s angle showed the highest reliability and agreement throughout the course of the disease. ADR was only reliable and showed good agreement between the observers when landmarks were clarified before measuring the radiographs. Thus, we recommend both parameters in clinical practice, provided a consensus is established for ADR. The observations for LAI had only fair agreement and ISS showed inconclusive agreement in our study. Thus, LAI and ISS can hardly be recommended in clinical practice.     

Cosmetic results after wire-guided biopsy of benign breast lesions

Background: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT).

Study Design: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy.

Results: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT.

Conclusions: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.     

Evaluation of gastric biopsies for neoplasia: differences between Japanese and Western pathologists.

Cited variations in the evaluation of gastric endoscopic biopsies for neoplasms between pathologists in Japan and those in the United States and Europe (the West) may have stemmed from several causes. The five-tiered group classification of the Japanese Research Society for Gastric Cancer (JRSGC) for interpretation of biopsies is not used in the West. Some differences may also exist in the morphologic criteria to reach a diagnosis of dysplasia or carcinoma. The goals of this study were to test the Western and Japanese classifications of gastric dysplasia and adenocarcinoma and to assess the differences between four Japanese and seven Western pathologists. One hundred biopsies, 20 from each of the five categories of the JRSGC scheme as determined by one observer, were collected. The Japanese observers used the JRSGC system, expressed in Roman numerals, whereas Western pathologists used a five- or six-tiered scheme expressed in diagnostic terms. Pairwise agreement was evaluated using k statistics within both groups. Consensus diagnosis on each biopsy was accepted as the opinion of the majority. The sensitivity and specificity of each reviewer for a certain diagnosis were also assessed. The intragroup agreements were moderate for both the Japanese (mean k = 0.663) and the Westerners (mean k = 0.652). The pairwise agreements between Japanese and Western observers were low (mean k = 0.542). Overall, the sensitivity was low for all Japanese observers for the diagnosis of dysplasia (38.7% vs 92.5%), and the sensitivity for the diagnosis of adenocarcinoma was high in both groups but higher among the Japanese observers (93.9% and 85.2%, respectively). Overall, the Japanese-Western interobserver agreement was moderate. The JRSCG scheme did not translate into higher interobserver agreement among Japanese observers. The sensitivity for the diagnosis of gastric adenocarcinoma was high for both groups, but the specificity was low among the Japanese. The cause seemed to be centered around the diagnosis of dysplasia in the Western system, which was a lesion frequently interpreted as carcinoma in Japan because of the different definitions of carcinoma in each system. Such a discrepancy might be important because it may explain some of the differences in the prevalence and prognosis of early gastric cancer between Japan and the West. An international effort is needed to harmonize morphologic criteria and analyze whether therapeutic consequences may stem from such discrepancies.     

Interobserver Agreement on Dermoscopic Features of Pigmented Basal Cell Carcinoma

BACKGROUND: A dermoscopic method based on the absence of a pigment network and the presence of at least one of six positive features has been described for diagnosis of pigmented basal cell carcinoma (BCC). OBJECTIVE: To evaluate the observers' global agreement and interobserver agreement on each dermoscopic parameter of the method recently proposed. METHODS: Dermoscopic images of 56 pigmented BCCs were examined by five observers with different degrees of experience in dermoscopy. RESULTS: An overall full agreement was reached for the absence of pigment network (k = 1). Very good agreement was detected for the presence of spoke wheel areas (k = 0.85) and arborizing vessels (k = 0.72), and good agreement was shown for ulceration (k = 0.49) and multiple blue-gray globules (k = 0.41). No agreement was identified on large blue-gray ovoid nests (k = 0.28) and leaflike areas (k = 0.26). CONCLUSION: We confirm the reproducibility of the method and show that ulceration, spoke wheel areas, and arborizing tel- angiectases represent the most robust positive parameters.     

The acetabulum in Perthes’ disease: Inter-observer agreement and reliability of radiographic measurements

Background and purpose

Perthes’ disease leads to radiographic changes in both the femoral head and the acetabulum. We investigated the inter-observer agreement and reliability of 4 radiographic measurements assessing the acetabular changes.

Patients and methods

We included 123 children with unilateral involvement, femoral head necrosis of more than 50%, and age at diagnosis of 6 years or older. Radiographs were taken at onset, and 1 year and 5 years after diagnosis. Sharp’s angle, acetabular depth-width ratio (ADR), lateral acetabular inclination (LAI), and acetabular retroversion (ischial spine sign, ISS) were measured by 3 observers. Before measuring, 2 of the observers had a consensus meeting.

Results

We found good agreement and moderate to excellent reliability for Sharp’s angle for all observers (intra-class correlation coefficient (ICC) > 0.80 with consensus, ICC = 0.46–0.57 without consensus). There was good agreement and substantial reliability for ADR between the observers who had had a consensus meeting (ICC = 0.62–0.89). Low levels of agreement and poor reliability were found for observers who had not had a consensus meeting. LAI showed fair agreement throughout the course of the disease (kappa = 0.28–0.52). The agreement between observations for ISS ranged from fair to good (kappa = 0.20–0.76).

Interpretation

Sharp’s angle showed the highest reliability and agreement throughout the course of the disease. ADR was only reliable and showed good agreement between the observers when landmarks were clarified before measuring the radiographs. Thus, we recommend both parameters in clinical practice, provided a consensus is established for ADR. The observations for LAI had only fair agreement and ISS showed inconclusive agreement in our study. Thus, LAI and ISS can hardly be recommended in clinical practice.Perthes’ disease leads to typical radiographic changes of the femoral head. Several authors have described simultaneous changes of the acetabular anatomy, such as hypertrophy, bicompartmental development, retroversion, and dysplastic changes (Yngve and Roberts 1985, Joseph 1989, Ezoe et al. 2006).Most measurements describing the radiographic changes of the acetabulum on anteroposterior (AP) pelvic radiographs have been validated in children with hip dysplasia. As the hip pathology and the morphological changes in Perthes’ disease are different from those in hip dysplasia, we wanted to assess inter-observer reliability and agreement of 4 commonly used acetabular measurements at the different stages of skeletal maturity in Perthes’ disease.     

A global assessment tool for evaluation of intraoperative laparoscopic skills

BACKGROUND: There is a pressing need for an intraoperative assessment tool that meets high standards of reliability and validity to use as an outcome measure for different training strategies. The aim of this study was to develop a tool specific for laparoscopic skills and to evaluate its reliability and validity. METHODS: The Global Operative Assessment of Laparoscopic Skills (GOALS) consists of a 5-item global rating scale. A 10-item checklist and 2 visual analogue scales (VAS) for competence and case difficulty were also used. During laparoscopic cholecystectomy, 21 participants were evaluated by the attending surgeon, by 2 trained observers and by self-assessment while dissecting the gallbladder from the liver bed. RESULTS: The intraclass correlation coefficient (ICC) for the total GOALS score was .89 (95% confidence interval [CI] .74 to .95) between observers, .82 (95% CI .67 to .92) between observers and attending surgeons, and .70 (95% CI .37 to .87) between participants and attending surgeons. The ICCs (observers) for the VAS (competence) and the checklist were .69 and .70, respectively. The mean total GOALS score (observers) for novices (postgraduate years [PGYs] 1 through 3) was 13 (95% CI 10.3 to 15.7) compared with 19.4 (95% CI 17.2 to 21.5) for experienced (PGY 4 through attending surgeons, P = .0006). The VAS demonstrated a difference in scores between novice and experienced participants (P = .001); however, the task checklist did not (P = .09). CONCLUSIONS: These data indicate that GOALS is feasible, reliable, and valid. They also suggest that it is superior to the task checklist and VAS for evaluation of technical skill by experienced raters. The findings support the use of GOALS in the training and evaluation of laparoscopic skills.     

American Society of Metabolic and Bariatric Surgery consensus statement on laparoscopic adjustable gastric band management

BackgroundLaparoscopic adjustable gastric band (LAGB) management continues to be an important part of many metabolic and bariatric surgery practices.ObjectivesTo replace the existing American Society for Metabolic and Bariatric Surgery (ASMBS) LAGB adjustment credentialing guidelines for physician extenders with consensus statements that reflect the current state of LAGB management.SettingASMBS Integrated Health Clinical Issues Committee.MethodsA modified Delphi process using a 2-stage consensus approach was conducted on LAGB management. Thirty-four consensus statements were developed following a literature search on a wide range of LAGB topics. A 5-point Likert scale was implemented to measure consensus agreement with a Delphi panel of 39 expert participants who were invited and agreed to participate in 2 rounds of Delphi questionnaires. Consensus was set a priori at 75% agreement, defined as the proportion of participants responding with agreement (i.e., 4 or 5) or disagreement (i.e., 1 or 2) on the Likert scale.ResultsConsensus was reached on 74% (25 of 34) of the LAGB management statements. In Delphi round 1, 95% (37 of 39) of the participants responded to 34 consensus statements; 21 of the statements (62%) met the 75% criteria for consensus. Thirty-one participants (80%) responded in round 2, shifting the agreement on 4 more statements to the 75% threshold.ConclusionThe ASMBS consensus statement on LAGB management is intended to guide practice with current evidence-based knowledge and professional experience. The ASMBS is not a credentialing body and does not seek to guide credentialing with this document.     

Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas

OBJECTIVE: To assess the oncologic and cosmetic outcomes in women with breast carcinoma who were treated with breast-conserving therapy using oncoplastic techniques with concomitant symmetrization of the contralateral breast. SUMMARY BACKGROUND DATA: Although breast-conserving therapy is the standard form of treatment for invasive breast tumors up to 4 cm, in patients with large, ill-defined, or poorly situated tumors, cosmetic results can be poor and clear resection margins difficult to obtain. The integration of oncoplastic techniques with a concomitant contralateral symmetrization procedure is a novel surgical approach that allows wide excisions and prevents breast deformities. METHODS: This is a prospective study of 101 patients who were operated on for breast carcinoma between July 1985 and June 1999 at the Institut Curie. The procedure was proposed for patients in whom conservative treatment was possible on oncologic grounds but where a standard lumpectomy would have led to poor cosmesis. Standard institutional treatment protocols were followed. All patients received either pre- or postoperative radiotherapy. Seventeen patients received preoperative chemotherapy to downsize their tumors. Mean follow-up was 3.8 years. Results were analyzed statistically using Kaplan-Meier estimates. RESULTS: Mean weight of excised material on the tumor side was 222 g. The actuarial 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmesis was favorable in 82% of cases. Preoperative radiotherapy resulted in worse cosmesis than when given postoperatively. CONCLUSIONS: The use of oncoplastic techniques and concomitant symmetrization of the contralateral breast allows extensive resections for conservative treatment of breast carcinoma and results in favorable oncologic and esthetic outcomes. This approach might be useful in extending the indications for conservative therapy.