Appendiceal neoplasms-A practical guide.

Appendiceal neoplasms (ANs) are a diverse group of pathologies that range from benign to malignant with widely varying prognoses. This article serves as an overview of the practical approach to evaluating and managing a patient with AN by reviewing the current literature and guidelines to provide a framework for the management of these nuanced pathologies.

Prevention of Implant Malposition in Latissimus Dorsi Myocutaneous Flap Breast Reconstruction Using an Acellular Dermal Matrix With Pectoralis Muscle Following Mastectomy for Breast Cancer: A Clinical Review.

Background: Latissimus dorsi myocutaneous (LDM) pedicled flaps are a well-established method for breast reconstruction in women with inadequate soft tissue coverage following mastectomy for breast cancer. The robust nature of the latissimus blood supply can accommodate immediate implant placement to increase breast volume; however, a known risk factor with this technique is implant malposition. By utilizing an acellular dermal matrix (ADM) in subpectoral implant-based LDM reconstruction, it is hypothesized that patients will experience a lower incidence of implant malposition. This 13-year retrospective review aims to evaluate the effectiveness of breast reconstruction using this technique. Methods: A retrospective review was conducted to identify all patients who underwent breast reconstruction following mastectomy with a LDM flap, subpectoral implant, and an ADM from 2007 to 2020 by a single surgeon at a single institution. Demographic and clinical data were collected and analyzed. Results: A total of 40 patients (LDM flaps, N = 51) were identified. Mean participant age was 50.25 ± 9.67 years and mean body mass index (BMI) was 30.85 ± 6.15 kg/m2. Comorbidities included hypertension (40.0%), diabetes mellitus (17.5%), and current smoking (25.0%). Mean follow-up was 31.52 ± 29.51 months. The most common complication was seroma formation (9.8%). No patients experienced implant malposition or flap necrosis. Conclusions: The use of a LDM flap and an ADM in implant-based breast reconstruction are each well described in the literature. This 13-year series supports the efficacy of these techniques utilized in combination to provide an aesthetic result while mitigating implant malposition during breast reconstruction of oncologic patients.

Patient demographics, clinicopathologic features, and outcomes in wild-type gastrointestinal stromal tumor: a national cohort analysis.

Wild-type KIT and PDGFRA gastrointestinal stromal tumors (GIST) are rare tumors with limited treatment options. We sought to determine the clinicopathologic features of wild-type GIST and identify factors that influence overall survival (OS) using a large national database. Retrospective evaluation of patients with wild-type GIST in the National Cancer Database (NCDB) was performed. Demographic, clinicopathologic, and treatment data were analyzed. Features associated with OS were investigated using Kaplan-Meier analysis and Cox proportional hazards model. 244 patients with median diagnosis age of 59 years (95% CI 57-63) were identified. The stomach was the most common primary site (57%) followed by the small intestine (35%). Surgical resection was performed on 85% of patients and 53% of patients received systemic therapy. Factors associated with decreased OS on multivariable analysis included small intestine primary (HR 2.72, 95% CI 1.13-6.69, P = 0.026) and > 5 mitoses per 50 HPF (HR 4.77, 95% CI 1.86-13.2, P = 0.001). Wild-type GISTs may be identified in older patients, with most arising in the stomach and small bowel. Surgery remains the principal treatment modality. Small intestine primary site and high mitotic count were associated with abbreviated OS.

Association Between Hereditary Lobular Breast Cancer Due to CDH1 Variants and Gastric Cancer Risk.

Importance: Hereditary cancer risk is informed by the presence of a germline gene variant more so than by family history of cancer. Objective: To assess gastric cancer risk among patients who received a diagnosis of hereditary lobular breast cancer (HLBC) owing to a germline loss-of-function variant in CDH1 by establishing prevalence of signet ring cell carcinomas among asymptomatic patients. Design, Setting, and Participants: A prospective cohort study of patients with germline CDH1 pathogenic or likely pathogenic (P/LP) variants at a quaternary medical center were enrolled between October 2017 and January 2021. Data analysis was performed in May 2021. Analyses for associations were performed for these 3 patient groups: (1) family history of breast cancer and no gastric cancer in the HLBC group; (2) family history of gastric cancer and no breast cancer in the hereditary diffuse gastric cancer (HDGC) group; and (3) family history of both breast and gastric cancers in the mixed group. Categorical variables were compared using the Pearson χ2 test. Main Outcomes and Measures: The primary end point of this study was the prevalence of occult signet ring cell carcinoma of the stomach in patients with HLBC. Personal and family medical history, genotype, and pathologic data from risk-reducing total gastrectomy and surveillance endoscopy were examined. Results: A total of 283 patients with CDH1 P/LP variants (199 [70.3%] were female, and 259 [91.5%] were White; median age, 48 years [range, 18-81 years]) were enrolled in a prospective study of HDGC. The cohort consisted of 151 families. Patients were categorized according to family history of breast and/or gastric cancer: HLBC 15.5% [44 of 283 patients]), HDGC (16.2% [46 of 283 patients]), and mixed (68.2% [193 of 283 patients]). The HLBC group included 31 distinct families with 19 CDH1 variants; 10 of those variants were also present in the HDGC and mixed groups (52.6% [10 of 19 variants]). Nearly all of the patients with HLBC (93.8% [15 of 16 variants]) who elected for risk-reducing total gastrectomy owing to their underlying CDH1 P/LP variant harbored occult signet ring cell gastric adenocarcinoma on final pathology (median age, 50 years [range, 21-67 years]). The prevalence of occult gastric cancer among asymptomatic patients in the HDGC group was similar (94.7% [18 of 19 of variants]; P = .98). Conclusions and Relevance: Carriers of CDH1 P/LP variants with no family history of gastric cancer exhibited high rates of occult signet ring cell gastric cancer. Germline CDH1 P/LP variants appear to have a highly penetrant gastric phenotype irrespective of family history. These data may prove useful for counseling families with CDH1 variants presumed to have HLBC.

Telesurgical Assessment: Using Smartphone Messaging to Efficiently Manage Postoperative Wounds.

Background: Telemedicine is an evolving field of interactions between physicians and patients remotely. Health care delivery, patient satisfaction, adherence, earlier diagnosis, increased access, and cost reduction are all areas that telemedicine has potential influence. One focus involves the use of photos in wound assessment. Today, many patients' smartphones can capture high-quality digital photographs, which can easily be transmitted. Postoperative patients are an ideal population for this, as they have a certain level of uncertainty with regard to the healing course, which can often lead to patients seeking out care in unnecessarily costly settings. These visits can lead to inefficient use of health care resources, especially when a telesurgical assessment (TSA) could provide appropriate care more efficiently. Objective: We present data collected from a series of patients who received a TSA to demonstrate the potential benefits of incorporating TSA into postoperative wound care. Methods/Clinical Presentation: Patients who underwent a procedure and contacted their surgeon within 2 weeks with concerns received a TSA, which included a discussion as well as photographs through smartphone. Their surgeon then determined further treatment steps, if any. Results: We experienced that 85% of patients did not require emergent treatment for their concerns, 46% were prescribed medications, whereas 39% of patients did not require any intervention. Conclusion: Our results show that TSAs alleviated patient concerns and provide resolutions, while saving resources and increasing satisfaction. Incorporating aspects of telemedicine into outpatient practice could be valuable, especially with postoperative wound checks.

Incisional Hernia After Percutaneous Endoscopic Gastrostomy Tube Placement: Importance of Avoiding the Linea Alba.

A gastrostomy tube passes from a patient's stomach through the abdominal wall and allows for direct enteral access. An alternative to an open gastrostomy, a percutaneous endoscopic gastrostomy (PEG) is typically favored because it is a less invasive option. However, a thorough understanding of the anatomy involved is paramount to prevent complications, regardless of what technique is chosen for placement. We present a case of an incisional hernia, which developed after the removal of a PEG tube placed through the midline of an abdominal wall, which is both a rare and avoidable complication. Placement of a PEG tube lateral to midline and avoiding the linea alba, an inherent weak point, will decrease the incidence of incisional hernias.

Projection of the prevalence of Parkinson's disease in the coming decades: Revisited.

OBJECTIVE: Previous studies have estimated future PD prevalence based on population aging. This study revisits that projection by accounting for the potential impact of declining rates of smoking. METHODS: The age- and gender-stratified smoking prevalence in the United States from 2000 to 2040 were obtained from the U.S. Census Bureau and the U.S. Surgeon General's Smoking Report. PD prevalence was estimated based on population aging with and without an account of the impact of declining smoking rates. Relative risks of 0.56 and 0.78 were applied for current and former smokers, respectively. RESULTS: Accounting for aging alone, ∼700,000 PD cases are predicted by 2040. After accounting for the declining smoking prevalence, ∼770,000 cases, an increase of ∼10% over the estimate without smoking, is predicted. CONCLUSIONS: If the epidemiological association of smoking and PD is causal, projecting future cases without considering smoking may underestimate disease burden, underscoring the urgency of adequate resource allocation. © 2017 International Parkinson and Movement Disorder Society.

An Expanded Retrospective Review of Trocar Site Hernias in Laparoscopic Gastric Bypass Patients.

BACKGROUND: Trocar site hernias (TSH) are reported in 0.3% to 5.4% of laparoscopic cases, depending on diameter and type. Most occur with trocars over 10 mm in diameter. Some recommend routine fascial closure, but this requires time, costs, pain, and increased infection rates. All prior series are based on clinical presentation alone. We examined the possibly underreported prevalence of asymptomatic TSH on postoperative computed tomography (CT) scans in a series of laparoscopic gastric bypass (LGBP) patients with unclosed port site fascia. MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, a retrospective review of all patients undergoing LGBP at our center from 2005 to 2014 was performed. All procedures were performed using dilating optical trocars up to 12 mm diameter, placed above the arcuate line. No fascial closures were performed. Any patients undergoing abdominal CT scanning for any reason in the study period were included; patients who had undergone a separate laparoscopic operation after LGBP but before CT were excluded. RESULTS: One thousand ninety-five patients were included; of these, 244 (22.3%) met study criteria, providing 732 port sites of 11 or 12 mm diameter to study. Only two fascial defects (0.27%), one in an 11-mm site and one in a 12-mm site, each in different patients, were identified. Both were nonpalpable, asymptomatic, and plugged with fat. CONCLUSIONS: Incisional hernias in dilating or optical access trocar sites are extremely rare in LGBP patients using trocars up to 12 mm, above the arcuate line. When found, they tend to be asymptomatic and at low risk for bowel strangulation. Routine closure of such fascial sites is likely unnecessary.