Cross-Sectional Imaging Studies: What Can We Learn and What Do We Need to Know?

Rapid, noninvasive imaging approaches can provide novel diagnostic information and, when effectively interpreted and implemented in a therapeutic strategy, can simplify procedures. Endovascular therapy of thoracic and abdominal aortic disease represents a dramatic shift in treatment of thoracoabdominal aortic disease, but one that requires a change in the knowledge base regarding both the morphology and pathophysiology of aortic disease and the interaction with interventional devices. As a result, the demands on cross-sectional imaging have increased commensurately with the complexity of the therapeutic options, but advances in cross-sectional imaging have kept pace. Current computed tomography (CT) and magnetic resonance imaging (MRI) technologies provide detailed morphologic assessment, and are advancing rapidly into more sophisticated physiologic evaluation of aortic disease. These advances may more effectively triage patients to appropriate therapy, or exclude patients from unnecessary invasive procedures. The information gleaned from CT and MRI studies is critical for the vascular surgeon who wants to identify appropriate vascular territories for intervention, plan a detailed approach, and develop sophisticated surveillance strategies.     

Can We Measure the Quality of Breast Surgical Care?

Many studies have demonstrated gaps in healthcare quality for all medical and surgical specialties including breast surgical care. How to optimally measure and improve quality has generated debate at the local, state, and national level. Attempts to judge medical performance by private companies using non-risk-adjusted administrative databases may not be accurate and may unfairly penalize surgical care. An overview of concepts to measure and improve quality of breast cancer care is presented with specific examples relevant to breast surgeons. Breast surgeons and their professional organizations need to take ownership of quality measure programs because others will surely do so if we do not. Participation in one or more of these programs is beneficial because peer performance comparison allows identification of potential areas for individual or institutional improvement and demonstrates the commitment of breast surgeons to quality improvement. This commitment may gain even greater importance if trends continue toward performance-based physician payment, patient steerage, licensure, and board certification.     

Robot-Assisted Pediatric Surgery: How Far Can We Go?

Background  

The purpose of this study was to assess the safety and feasibility of performing robot-assisted pediatric surgery using the da Vinci Surgical System in a variety of surgical procedures.     

Univentricular Heart: Can We Alter the Natural History?

Surgical treatment must be considered for patients with univentricular heart in view of their poor natural history. Since one of the major factors influencing the natural history of this malformation is the amount of pulmonary blood flow, we discuss the potential surgical options by separately considering the two main pathophysiological situations: univentricular heart with restricted pulmonary blood flow, and univentricular heart with unrestricted pulmonary blood flow. We have reviewed the early and late results of surgical treatment based on our experience with 19 patients and the data from the literature. Temporary relief of symptoms can be provided by palliative operations (systemic-pulmonary shunt, atrioseptectomy, enlargement of the outlet foramen, pulmonary artery banding, or palliative Mustard or Senning procedure). "Corrective" surgery, by means of either a modified Fontan operation or ventricular septation, carries a high early mortality (about 30%) and a high early and late morbidity, with only 50% of survivors enjoying an asymptomatic life. Studies of the long-term efficacy of palliative operations as well as our experience and that of others with "corrective" operations, which have a relatively short follow-up, do not yet indicate whether presently available surgical procedures can alter the natural history of patients with univentricular heart.     

Current Understanding and Management of Plasma Cell Mastitis: Can We Benefit from What We Know?

BackgroundPlasma cell mastitis (PCM), also known as mammary duct ectasia, is a chronic nonbacterial breast inflammation characterized by duct expansion and plasma cell infiltration. The severe and intense clinical manifestations profoundly affect the quality of life of female patients. Although the pathological process of PCM is known to include four stages (duct dilatation, inflammation, abscess and fistula), there is still lack of imaging techniques and serum markers with high specificity in clinical practice. Due to recurrent acute attacks and the prolonged healing process of the disease, most patients choose to accept mastectomy.SummaryWe searched for studies, reports and reviews referring to PCM in the past 20 years; more than half of the results were related to animal studies, and little attention has been paid to human beings, which may explain the frequent misdiagnosis of PCM as breast cancer and the limited treatment options. This review focuses on the current diagnostic methods and markers for PCM and hierarchically discusses the typical clinical features, etiological causes and relevant molecular mechanisms of PCM.Key MessagesWe herein highlight the urgent need to develop more specific and sensitive biomarkers in the clinical laboratory. It will help to establish a standardized flowchart for the diagnosis and treatment of PCM in order to improve recovery for female patients.     

Can We Confidently Study VO2 Kinetics in Young People?

The study of VO₂ kinetics offers the potential to non-invasively examine the cardiorespiratory and metabolic response to dynamic exercise and limitations to every day physical activity. Its non-invasive nature makes it hugely attractive for use with young people, both healthy and those with disease, and yet the literature, whilst growing with respect to adults, remains confined to a cluster of studies with these special populations. It is most likely that this is partly due to the methodological difficulties involved in studying VO₂ kinetics in young people which are not present, or present to a lesser degree, with adults. This article reviews these methodological issues, and explains the main procedures that might be used to overcome them.

Key points

• The VO₂ kinetic response to exercise represents the combined efficiency of the cardiovascular, pulmonary and metabolic systems, and an accurate assessment of the response potentially provides a great deal of useful information via non-invasive methodology.
• An accurate assessment of the VO₂ kinetic response is however inherently difficult with children and especially those with reduced exercise tolerance, due primarily to the apparent breath-by-breath noise which masks the true underlying physiological response, and the small amplitudes of the response signal.
• Despite this, it is possible to assess and quantify the VO₂ kinetic response with children if appropriate steps are taken to apply carefully selected methodologies and report response variables with confidence intervals. In this way, both the researcher and the reader can be confident that the data reported is meaningful.

Key words: Children, oxygen kinetics, methodology     

Radical Surgery for Mesothelioma: How Can We Obtain Evidence?

World Journal of Surgery - Asbestos exposure in industry and construction sites in the 1960s and 1970s has left a legacy of mesothelioma, a diffuse pleural cancer, with a lag time of 40 to 50 years...     

Understanding Hospital Readmissions After Pancreaticoduodenectomy: Can We Prevent Them?

Introduction

The morbidity and mortality of pancreaticoduodenectomy (PD) have significantly decreased over the past decades to the point that they are no longer the sole indicators of quality and safety. In recent times, hospital readmission is increasingly used as a quality metric for surgical performance and has direct implications on health-care costs. We sought to delineate the natural history and predictive factors of readmissions after PD.

Methods

The clinicopathologic and long-term follow-up data of 1,173 consecutive patients who underwent PD between August 2002 and August 2012 at the Massachusetts General Hospital were reviewed. The NSQIP database was linked with our clinical database to supplement perioperative data. Readmissions unrelated to the index admission were omitted.

Results

We identified 173 (15 %) patients who required readmission after PD within the study period. The readmission rate was higher in the second half of the decade when compared to the first half (18.6 vs 12.3 %, p?=?0.003), despite a stable 7-day median length of stay. Readmitted patients were analyzed against those without readmissions after PD. The demographics and tumor pathology of both groups did not differ significantly. In the multivariate logistic regression analysis, pancreatic fistula (18.5 vs 11.3 %, OR 1.86, p?=?0.004), multivisceral resection at time of PD (3.5 vs 0.6 %, OR 4.02, p?=?0.02), length of initial hospital stay >7 days (59.5 vs 42.5 %, OR 1.57, p?=?0.01), and ICU admissions (11.6 vs 3.4 %, OR 2.90, p?=?0.0005) were independently associated with readmissions. There were no postoperative biochemical variables that were predictive of readmissions. Fifty percent (n?=?87) of the readmissions occurred within 7 days from initial operative discharge. The reasons for immediate (≤7 days) and nonimmediate (>7 days) readmissions differed; ileus, delayed gastric emptying, and pneumonia were more common in early readmissions, whereas wound infection, failure to thrive, and intra-abdominal hemorrhage were associated with late readmissions. The incidences of readmissions due to pancreatic fistulas and intra-abdominal abscesses were equally distributed between both time frames. The frequency of readmission after PD is 15 % and has been on the uptrend over the last decade.

Conclusion

The complexity of initial resection and pancreatic fistula were independently associated with hospital readmissions after PD. Further efforts should be centered on preventing early readmissions, which constitute half of all readmissions.