The impact of a surgical assessment unit on numbers of general surgery outliers.

AIMS: Patient care and efficiency outcomes are improved if acute patients admitted to non-specialty (outlier) wards are minimised.1 Assessment units may help to reduce numbers of outlier patients.2 A surgical assessment unit (SAU) was recently established at Middlemore Hospital. We aimed to determine the impact of its introduction on numbers of general surgery outliers on post-acute ward rounds. METHODS: A 10-bed SAU was introduced in July 2015, coinciding with the closure of 20 beds on the general surgical wards. The numbers and locations of patients on post-acute ward rounds before and after the establishment of the SAU were compared. A student two-tailed t-test was used for statistical comparisons, with p<0.05 considered significant. RESULTS: A total of 1,462 patient locations were analysed from 71 post-acute ward rounds. There were similar overall numbers of post-acute patients before and after the introduction of the SAU (mean 21 vs 20, p=0.33). There were fewer post-acute patients in outlier wards after the introduction of the SAU (mean 1.7 before vs 0.8 after, p=0.04). CONCLUSION: Despite a net reduction in general surgery beds and no change in the overall number of post-acute patients, the establishment of a SAU was associated with a reduction in outliers.

Columnar cell change with atypia (flat epithelial atypia) on breast core biopsy-outcomes following open excision.

Columnar cell change with atypia (CCCA) is a relatively recently recognized pathologic breast entity considered to be a risk factor for subsequent development of breast carcinoma. The aim of this study was to investigate the significance of finding CCCA on breast core biopsy, by establishing the frequency of other breast pathology on subsequently performed surgical excision specimens. All cases with CCCA as the most advanced lesion on core biopsy were reviewed. After excision, another advanced proliferative lesion was identified in 17 (33%) patients, including three patients (6%) with in situ or invasive carcinoma. An additional five patients (10%) were concurrently diagnosed with primary breast carcinoma at other sites. These findings indicate that when CCCA is found on core biopsy, open surgical biopsy of the relevant area should be performed and that workup of both breasts should be undertaken to exclude coexistent breast carcinoma at alternative sites.

Gastric cancer location and histological subtype in Pacific people and Maori defies international trends.

AIMS: Gastric cancer location and histopathology in Pacific people (mostly of Samoan, Tongan, Niuean, or Cook Islands origin) and Maori in New Zealand has not been specifically examined. METHODS: A retrospective review of all histologically-proven new cases of gastric adenocarcinoma and gastro-oesophageal adenocarcinoma at Middlemore Hospital (Auckland, New Zealand) from June 2003-June 2009 was conducted. Demographic data, clinical presentation, diagnostic/ staging investigations and surgical outcomes were recorded. RESULTS: There were 133 patients of whom 79 (59%) were male. Forty-nine (37%) patients were of Pacific ethnicity and 34 (26%) were Maori. Maori (59.3 years; p=0.01) and Pacific (64.5 years; p=0.01) patients were significantly younger at diagnosis compared to European patients (77.2 years). European patients had more proximal tumours (n=18; 47%) compared to Pacific (n=5; 10%) and Maori (n=4; 12%) patients (p= 0.01). Pacific (n=25; 51%) and Maori (n=21; 62%) patients had a significantly higher percentage of diffuse-type gastric cancer compared to European (n=7; 18%) patients. There was no difference in stage of presentation between ethnic groups. CONCLUSIONS: Maori and Pacific patients present with gastric cancer at higher rates and at a younger age. They have a predominance of diffuse-type antral and gastric body cancers which stand in contrast to global trends in gastric cancer.

Intraoperative ultrasonography-guided excision of nonpalpable breast lesions.

BACKGROUND: The use of intraoperative ultrasonography (US) to localize and guide excision of nonpalpable breast lesions has advantages over other techniques. It avoids the need for additional resources and minimizes patient morbidity. METHODS AND RESULTS: The technique of surgeon-performed US-guided excision as described in this report is straightforward and safe, easily reproducible, and suitable for teaching. CONCLUSIONS: The US-guided breast excision technique is predictable and accurate, minimizes costs, and is advocated as an appropriate method for US-visible lesions requiring surgical excision. With appropriate training, breast surgeons can easily acquire the necessary skills to incorporate the use of US in their surgical practice.

The role of ultrasound in the management of breast disease.

Surgeon-performed ultrasound has also been increasingly utilised by breast surgeons in particular, who find ultrasound an invaluable tool in the office to assist in the management of breast patients, and also in the operating room where it can be used to directly guide excision of impalpable breast lesions without the use of hookwires2,3. In the future, the role of ultrasound will continue to grow, particularly with the advent of 3-D ultrasound, and in the evolving area of breast lesion ablation techniques using modalities such as radiofrequency ablation or laser therapy. Ultrasound is a very important tool in the assessment and management of breast disease and it has dramatically changed the way breast cancer patients are managed.

Accuracy of sentinel node biopsy for breast cancer using blue dye alone.

Blue dye alone (BDA), lymphoscintigraphy alone, or, a combination of the two techniques are used for sentinel node biopsy (SNB) in breast cancer. This study reviews the effectiveness of the SNB technique using BDA by measuring the node identification rate and comparing the cohort node positivity with expected rates from established nomograms. A consecutive case series was examined from the database. This included the learning experience of six surgeons. Patients with unifocal tumors estimated at less than 31 mm were eligible. The tumor and axillary nodal histology was recorded. Published data were then used to calculate and predict node positivity rates in the study according to the size and grade of the tumors. There were 332 SNB procedures from 2001 to 2008. BDA successfully identified nodes in 94.6% (314/332) of the cases. The identification rate improved with experience. In patients with invasive cancer, 28.4% (85/299) of SNB were found to be positive for metastases or micrometastases. The node identification rate and the node positivity rate were found to be within published predicted ranges for the size and grade of the study tumors. The SNB with BDA was found to be effective in identifying sentinel nodes (SLN) in breast cancer. Surgeon experience was a factor in the success of the technique. Rates of detecting metastases were consistent with internationally published data, suggesting that BDA may perform as well as other techniques in experienced hands.