Contralateral prophylactic mastectomy.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is often discussed as a treatment option for women with a diagnosis of unilateral breast cancer. The purpose of this study was to identify the prevalence of pathology within the specimen at the time of CPM and to evaluate potential risk factors. METHODS: Patients with a unilateral breast malignancy who underwent CPM were identified from the database of Scott and White Breast Cancer Clinic. A retrospective cohort study comparing disease status and various exposure parameters was conducted via chart review. RESULTS: Of the 301 patients who met the inclusion criteria, there were 14 cases (4.7%) with malignancy and 45 cases (15.0%) with moderate-to-high risk lesions. Multivariate analysis demonstrated 2 independent factors predictive of malignant or moderate-to-high risk lesions: age >54 years and lobular histology in the original specimen. CONCLUSIONS: The prevalence of malignant and premalignant lesions at the time of CPM was nearly 1 in 5.

Symptomatic Bochdalek hernia in an adult.

BACKGROUND AND OBJECTIVES: Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Symptomatic Bochdalek hernias in adults are infrequent and may lead to gastrointestinal dysfunction or severe pulmonary disease. We describe our experience with this rare entity. METHODS: A retrospective chart review was performed on a single patient for data collection purposes. RESULTS: The patient is a morbidly obese 53-year-old female who presented with epigastric pain and diffuse abdominal tenderness. Computed tomography scans of the chest and abdomen revealed a small posterior diaphragmatic defect containing gastric fundal diverticulum. Laboratory work and imaging revealed no other findings. Laparoscopic repair of the Bochdalek hernia was done via an abdominal approach and utilized primary closure with an AlloDerm patch apposed to the defect. The patient has had significant clinical improvement and continues to do well at 9 months postoperatively. CONCLUSION: Laparoscopic repair of symptomatic adult Bochdalek hernias can be performed successfully and may result in significant clinical improvement.

Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures.

BACKGROUND: Thyroidectomy has traditionally been performed as an inpatient hospital procedure, but low risk and high patient tolerance make it acceptable as an outpatient procedure. STUDY DESIGN: All thyroidectomies performed by a single surgeon between March 2003 and June 2009 were retrospectively and prospectively reviewed as planned outpatient or planned inpatient operations, noting the patient's American Society of Anesthesiologists (ASA) classification, success of completion as an outpatient procedure, time to same-day discharge, postoperative emergency room visit, hospital admission, and complications. RESULTS: Overall, 1,136 of 1,242 thyroidectomies were planned as outpatient procedures and 1,063 (93.6%) were successfully completed as such. Including 1 outpatient procedure initially planned as an inpatient procedure, 1,064 outpatient procedures were performed, of which 613 were total and 451 less-than-total thyroidectomies. These outpatient procedures had a mean time to day-surgery discharge of 2 hours and 42 minutes. Of discharged outpatients, a postoperative emergency room visit within 30 days occurred in 83 cases (7.8%), with subsequent hospital admission in 25 of these patients (2.3%). Excluding 153 cases of isolated and self-limited asymptomatic hypocalcemia (14.4%), substantial complications occurred in 122 discharged outpatients (11.5%), including 56 symptomatic hypocalcemias (5.2%), 39 transient recurrent laryngeal nerve injuries (3.7%), 4 permanent recurrent laryngeal nerve injuries (0.4%), and 2 hematomas (0.19%). None of the patients with postoperative hematoma required bedside decompression and only 1 occurred within 24 hours of the outpatient procedure. Discharged outpatient thyroidectomy patients were younger (53 years versus 60 years; p < 0.0001) and healthier (2.3 ASA versus 3.0 ASA; p < 0.0001) than planned inpatient thyroidectomies. CONCLUSIONS: Outpatient thyroidectomy in experienced hands is safe and reasonable with favorable patient acceptance and the potential for substantial health care cost savings.