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Several randomized trials have been performed comparing partial breast irradiation (PBI) and whole breast irradiation (WBI) though controversy remains, including regarding differences by PBI technique. We performed a meta-analysis to compare results between WBI versus PBI and between PBI techniques. A systematic review was performed to identify modern randomized studies listed in MEDLINE from 2005 to 2020. PBI trials were divided into external beam radiation and brachytherapy techniques, with intraoperative radiation excluded. A Bayesian logistic regression model evaluated the risk of ipsilateral breast tumor recurrence (IBTR) and acute and chronic toxicities. The primary outcome was IBTR at 5 years with WBI compared with PBI. A total of 9758 patients from 7 studies were included (4840-WBI, 4918-PBI). At 5 years, no statistically significant difference in the rate of IBTR was noted between PBI (1.8%, 95% HPD 0.68–3.2%) and WBI (1.7%, 95% HPD 0.92–2.4%). By PBI technique, the 5-year rate of IBTR rate for external beam was 1.7% and 2.2% for brachytherapy. Rates of grade 2 + acute toxicity were 7.1% with PBI versus 47.5% with WBI. For late toxicities, grade 2/3 rates were 0%/0% with PBI compared with 1.0%/0% with WBI. IBTR rates were similar between PBI and WBI with no significant differences noted by PBI technique; PBI had reduced acute toxicities compared to WBI. Because studies did not provide toxicity data in a consistent fashion, definitive conclusions cannot be made with additional data from randomized trials needed to compare toxicity profiles between PBI techniques.

Several randomized trials have been performed comparing partial breast irradiation (PBI) and whole breast irradiation (WBI) though controversy remains, including regarding differences by PBI technique. We performed a meta-analysis to compare results between WBI versus PBI and between PBI techniques.A systematic review was performed to identify modern randomized studies listed in MEDLINE from 2005 to 2020. PBI trials were divided into external beam radiation and brachytherapy techniques, with intraoperative radiation excluded. A Bayesian logistic regression model evaluated the risk of ipsilateral breast tumor recurrence (IBTR) and acute and chronic toxicities. The primary outcome was IBTR at 5 years with WBI compared with PBI.A total of 9758 patients from 7 studies were included (4840-WBI, 4918-PBI). At 5 years, no statistically significant difference in the rate of IBTR was noted between PBI (1.8%, 95% HPD 0.68-3.2%) and WBI (1.7%, 95% HPD 0.92-2.4%). By PBI technique, the 5-year rate of IBTR rate for external beam was 1.7% and 2.2% for brachytherapy. Rates of grade 2 + acute toxicity were 7.1% with PBI versus 47.5% with WBI. For late toxicities, grade 2/3 rates were 0%/0% with PBI compared with 1.0%/0% with WBI.IBTR rates were similar between PBI and WBI with no significant differences noted by PBI technique; PBI had reduced acute toxicities compared to WBI. Because studies did not provide toxicity data in a consistent fashion, definitive conclusions cannot be made with additional data from randomized trials needed to compare toxicity profiles between PBI techniques.

Congenital diaphragmatic hernia (CDH) is an infrequent occurrence but can present a complex situation for physicians. The respiratory system can be affected in various ways. Primary closure often is not feasible and many autologous tissue, prosthetic and biosynthetic options exist to assist with closure. Many of the sequelae of this repair manifest later in childhood with revision being common for many reasons, most commonly for reherniation.A 7-month-old infant who underwent CDH repair in the first week of life presented to a plastic surgeon with right chest wall depression inconsistent with the commonly seen post-thoracotomy scoliosis or pectus deformity. A trial of non-operative management failed as serial imaging showed no improvement. As the patient aged, she and her family became more dissatisfied with the noticeable chest wall defect. At 7 years after the initial CDH repair, chest wall reconstruction was successfully performed using a poly (D,L-lactide) acid plating system. This case illustrates a unique approach to primary pediatric chest wall reconstruction after arrest of chest wall growth secondary to primary CDH repair and also highlights the importance of correct surgical technique in pediatric patients, especially when operating near bone growth centers. Keywords: Congenital diaphragmatic hernia, Resorb X®, Chest wall reconstruction

Rotational anomalies occur when there is an abnormal arrest of rotation in the embryonic gut during development. The characteristic population affected is considered to be infants or young children, but in clinical practice, can be found in older children and adults as well. In these patients, the Ladd procedure is performed, whereby the abdomen is opened using traditional incisions, such as the midline laparotomy, for full visualization of the abdominal cavity. Despite providing excellent visualization, approaches such as this carry both increased surgical-site morbidity and an often-displeasing incision and visible scar. In this case report, we advocate consideration of the low transverse pfannenstiel incision and approach used traditionally in cosmetic and reconstructive abdominoplasty for surgical access to the abdomen for Ladd’s procedure. We believe that this alternative approach provides superior visualization without compromising the integrity or the esthetics of the abdominal wall in appropriate populations desiring to minimize the morbidity and visibility of their scar. Keywords: adult, adolescent, aesthetics, abdominoplasty, Ladd procedure, open

Introduction This study analyzed the cost-efficacy of intraoperative radiation therapy (IORT) compared with whole-breast irradiation (WBI) and accelerated partial-breast irradiation (APBI) for early-stage breast cancer. Materials and Methods Data for this analysis came from 2 phase III trials: the TARGIT (Targeted Intraoperative Radiotherapy) trial and the ELIOT (Electron Intraoperative Radiotherapy) trial. Cost analyses included a cost-minimization analysis and an incremental cost-effectiveness ratio analysis including a quality-adjusted life-year (QALY) analysis. Cost analyses were performed comparing IORT with WBI delivered using 3-dimensional conformal radiotherapy (3D-CRT), APBI 3D-CRT, APBI delivered with intensity-modulated radiotherapy (IMRT), APBI single-lumen (SL), APBI multilumen (ML), and APBI interstitial (I). Results Per 1000 patients treated, the cost savings with IORT were $3.6-$4.3 million, $1.6-$2.4 million, $3.6-$4.4 million, $7.5-$8.2 million, and $2.8-$3.6 million compared with WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I, respectively, with a cost decrement of $1.6-$2.4 million compared with APBI 3D-CRT based on data from the TARGIT trial. The costs per QALY for WBI 3D-CRT, APBI IMRT, APBI SL, APBI ML, and APBI I compared with IORT were $47,990-$60,002; $17,335-$29,347; $49,019-$61,031; $108,162-$120,173; and $36,129-$48,141, respectively, based on data from the ELIOT trial. These results are consistent with APBI and WBI being cost-effective compared with IORT. Conclusion Based on cost-minimization analyses, IORT represents a potential cost savings in the management of early-stage breast cancer. However, absolute reimbursement is misleading, because when additional medical and nonmedical costs associated with IORT are factored in, WBI and APBI represent cost-effective modalities based on cost-per-QALY analyses. They remain the standard of care.

Importance Ductal carcinoma in situ (DCIS) of the breast represents a disease process that continues to increase in incidence with treatment paradigms that continue to evolve. Greater access to long-term data from large observational studies addressing the natural history of the disease has contributed to changes in treatment paradigms and put into question traditional management strategies. Observations While recent analyses have suggested that a more conservative approach to the management of DCIS without surgical intervention or radiation therapy may be advisable based on breast cancer mortality data, there is a lack of level 1 or prospective evidence to support the widespread adoption of these approaches. Currently, surgery remains the standard of care for the initial treatment of DCIS. Adjuvant radiation therapy (RT) has consistently demonstrated a reduction in the risk of local recurrence following breast-conserving surgery (BCS), even in “low-risk” populations of patients. Invasive recurrences following BCS are associated with increases in breast cancer mortality. Questions that remain to be answered include (1) what constitutes an acceptable risk of local recurrence, (2) what are the costs associated with managing local recurrences compared with RT given initially after BCS (particularly in light of data supporting shorter courses of RT), and (3) what are the benefits of endocrine therapy on local recurrence, and do they justify the additional toxic effects and potential noncompliance with their long-term administration? Conclusions and Relevance Surgery and RT remain standard of care treatment options in the management of DCIS. Future studies are required to identify cohorts of patients in which RT can be safely omitted as well as to evaluate whether short-course RT alone may represent a better option than endocrine therapy with respect to compliance, toxic effects, cost and local control following BCS.

No universally accepted method of flap monitoring exists, and several techniques are in use. Repeated physical examination is most popular and is often supplemented with a handheld, external Doppler, and/or implantable Doppler probes; near-infrared spectroscopy is less commonly used. We investigated the nursing and resident house staff's experience and confidence with physical exam for flap monitoring. Also, a consecutive series of 38 patients with free flaps were monitored using physical examination, external Doppler, implantable arterial and venous Doppler probes, and near-infrared spectroscopy. Five patients developed signs of microvascular complications within 3 days of surgery; all were explored and salvaged. Neither the residents nor the nursing staff were universally trained or experienced in flap monitoring by physical exam. In all patients, changes in the appearance of the flap suggestive of a microvascular complication lagged 30 to 60 minutes after the adjunctive monitoring methods indicated that a problem had occurred. Near-infrared spectroscopy was the first warning sign in four of the five patients. Two patients were explored before thrombosis of the anastomoses occurred. Near-infrared spectroscopy may identify early microvascular complications more reliably than physical examination, external Doppler, or implantable Doppler.

A lack of consistent data are available about optimizing cosmetic outcomes, reducing potential treatment-related toxicities, and defining important prognostic factors for women undergoing postmastectomy radiation therapy (PMRT) following breast reconstruction. A Medline search was conducted to summarize the latest data on the topic with a focus on both autologous and tissue expander/implant (E/I) reconstructions. Autologous tissue reconstructions (ATR) represent less than 20 % of all breast reconstructions and include several techniques. A multitude of small studies have suggested that ATR is associated with improved cosmetic outcomes and similar rates of complications compared with E/I reconstructions. With regards to ATRs, the addition of PMRT has been suggested but not definitively associated with a decrement in cosmetic outcome compared with patients not receiving radiation. Expander/implant-based reconstruction appears to be the most common form of breast reconstruction with large, prospective, and retrospective series demonstrating that 20-30 % of patients may require some type of revision/replacement with long-term follow-up based on large series from Memorial Sloan Kettering Cancer Center and the Cleveland Clinic. Whereas PMRT and the addition of regional irradiation has been traditionally associated with increased complications and worse outcomes with E/I reconstruction, recent data suggest that no difference in perioperative complications exists in patients receiving PMRT using modern techniques.

Congenital anal web is a rare form of anorectal malformation. In cases of delayed diagnosis, patients can present with signs ranging from mild constipation to complete bowel obstruction. The diagnosis is made by thorough anorectal inspection and a digital rectal exam. We present the case of a 9-month-old boy with Down's syndrome with chronic constipation secondary to an anal web. To our best knowledge, this is the first report of an anal web in a patient with Down's syndrome presenting with severe chronic constipation.

Klippel-Trenaunay syndrome (KTS) is a congenital disorder that presents with a classic triad of findings including varicose veins or venous malformations, capillary malformation, and soft tissue or bone hypertrophy of the affected limbs. These patients can have lymphatic malformations and deep venous anomalies comprised of hypoplasia, aplasia, or venous incompetence. The authors describe a case of a patient with KTS who had liposuction for limb hypertrophy and developed fat embolism.

Summary Background Although free tissue breast reconstruction has been increasingly used, it remains challenging to perform outside of specialized centers due to facility and personnel limitations. We describe a preclinical study highlighting the feasibility of a pedicled, superior epigastric artery perforator (SEAP) flap utilizing lower abdominal tissues similar to a transverse rectus abdominus myocutaneous (TRAM) reconstruction, but with decreased donor-site morbidity. Methods Fresh cadavers were dissected generating a total of 32 SEAP flaps. These flaps were subsequently studied for transposition potential and vascularity utilizing computed tomographic (CT) imaging. Results An obvious, single, dominant SEAP was appreciated, and a developed flap was routinely capable of reaching either nipple–areola complex with simple interposition. Cadaveric CT imaging revealed global contrast filling in each dissected hemi-abdomen tested. Conclusions We describe a preclinical study utilizing a novel pedicled, SEAP flap for aesthetic breast reconstruction. While this will not obviate the use of free tissue transfer, it may add to the surgical armamentarium for aesthetic restoration in the breast cancer patient.

Background The goal of this study was to evaluate the relationship between body mass index, preoperative weight loss, and patient satisfaction in breast reconstruction with abdominally based free flaps. Methods A custom survey with overall, breast, and abdomen questions was sent to patients who underwent abdominally based free flap breast reconstruction over the past 4 years. Clinical data were collected for patients who returned surveys. Data analysis was performed based on body mass index and percentage weight loss before surgery. Results One hundred seventy-nine surveys were sent. Ninety-two patients (51.4 percent) responded. Normal weight patients versus overweight patients did not have statistically significant differences in any satisfaction scores. Overweight patients had higher overall satisfaction (p = 0.01), breast-specific satisfaction (p = 0.01), and abdomen-specific satisfaction (p = 0.02) compared with obese patients. Normal weight patients had higher breast-specific satisfaction (p = 0.05) and abdomen-specific satisfaction (p = 0.03) scores compared with obese patients. Patients with significant preoperative weight loss were more satisfied with feeling of breasts in clothes (p = 0.01), social appearance (p = 0.05), and current abdominal appearance (p = 0.01) compared with patients with moderate preoperative weight loss. Overall, breast- and abdomen-specific satisfaction scores decreased with increase in pannus thickness. Conclusions Patient satisfaction with abdominally based free flap breast reconstruction was highest in patients with normal body mass index and lowest in obese patients. Overweight or obese patients should be encouraged to participate in healthy weight loss programs to achieve improved postoperative satisfaction. Clinical question/level of evidence Therapeutic, IV.

Sciatic hernia is defined as a protrusion of abdominal viscera through the greater or lesser sciatic foramina. This type of hernia represents the rarest of all hernias with\100 total reported cases—of which only ten relate to children [1]. The incidence is equal in both sexes [2]. While no underlying etiology for sciatic hernias has been identified, the typical scenario involves older, adult females who present with chronic pelvic pain with or without mass in the thighs or buttocks. To date, less than ten cases of congenital sciatic hernias were reported, undergoing an open repair [2–7]. We present a case of a neonate with a congenital sciatic hernia that was repaired with laparoscopic assistance. To our knowledge, this is the first laparoscopically assisted congenital sciatic hernia repair in a preterm infant.

Abdominal closure is a complex surgical problem in intestinal transplant recipients with loss of abdominal domain, as graft exposure results in profound morbidity. Although intraoperative coverage techniques have been described, this is the first report of preoperative abdominal wall augmentation using tissue expanders in patients awaiting intestinal transplantation. We report on five patients who received a total of twelve tissue expanders as a means to increase abdominal surface area. Each patient had a compromised abdominal wall (multiple prior operations, enterocutaneous fistulae, subcutaneous abscesses, stomas) with loss of domain and was identified as high risk for an open abdomen post-transplant. Cross-sectional imaging and dimensional analysis were performed to quantify the effect of the expanders on total abdominal and intraperitoneal cavity volumes. The overall mean increase in total abdominal volume was 958 cm(3) with a mean expander volume of 896.5 cc. Two expanders were removed in the first patient due to infection, but after protocol modification, there were no further infections. Three patients eventually underwent small bowel transplantation with complete graft coverage. In our preliminary experience, abdominal tissue expander placement is a safe, feasible, and well-tolerated method to increase subcutaneous domain and facilitate graft coverage in patients undergoing intestinal transplantation.

Obesity, which is becoming endemic in the United States, causes a significant challenge for reconstructive surgeons. This study evaluates postoperative complications and impact of weight loss in the high body mass index (BMI) population undergoing breast reconstruction with abdominal free flaps. A retrospective review of 182 consecutive patients was performed. Patients were divided into groups according to their BMI at the time of surgery (preoperative BMI) and presence of weight loss, and data were compared among groups. Multivariate analysis of effect of preoperative BMI on complications revealed that overall flap (P = 0.008) and donor (P = 0.016) complication rates were significantly higher in the obese group. Analysis of preoperative weight loss did not yield a statistically significant reduction in flap (P = 0.5161) or donor (P = 0.8034) complication rates. Univariate analysis showed that higher preoperative BMI is associated with higher risk of systemic complications (P = 0.027). It is important to inform patients preoperatively that weight loss, although beneficial for ease of procedure and quality of life, does not diminish their increased risk of complications. Body mass index during surgery is the most important predictor of complications.

Background and objectives Transumbilical laparoscopic-assisted appendectomy (TULAA) carries a high risk for surgical site infection. We investigated the effect of a bio-occlusive umbilical vacuum dressing on wound infection rates after TULAA for patients with acute appendicitis and compared to it with a conventional 3-port appendectomy with a nonvacuum dressing. Methods This study was a retrospective chart review of 1377 patients (2-20 years) undergoing laparoscopic appendectomy for acute appendicitis in 2 tertiary care referral centers from January 2007 through December 2012. Twenty-two different operative technique/dressing variations were documented. The 6 technique/dressing groups with >50 patients were assessed, including a total of 1283 patients. Results The surgical site infection rate of the 220 patients treated with TULAA and application of an umbilical vacuum dressing with dry gauze is 1.8% (95% CI, 0.0-10.3%). This compares to an infection rate of 4.1% (95% CI, 1.3-10.5%) in 97 patients with dry dressing without vacuum. In the 395 patients who received an umbilical vacuum dressing with gauze and bacitracin, the surgical site infection rate was found to be 4.3% (95% CI, 2.7-6.8%). Conclusions Application of an umbilical negative-pressure dressing with dry gauze lowers the rate of umbilical site infections in patients undergoing transumbilical laparoscopic-assisted appendectomy for acute appendicitis.

Introduction: Toxic epidermal necrolysis (TEN) and Stevens–Johnson syndrome (SJS) are severe, potentially fatal cutaneous reactions to medications affecting only 1–2 per million individuals each year. They present as tenderness, erythema and blistering of both the skin and mucus membranes. We describe a case of Stevens–Johnson syndrome linked to piperacillin–tazobactam treatment, which is a previously unreported cause and a rare occurrence in postoperative patients. Case Report: A 37­year­old female with chronic pancreatitis post­total pancreatectomy with auto­islet transplant was re­admitted on postoperative day 12 with abdominal pain and leukocytosis. Her workup revealed a small intra­ abdominal fluid collection suspicious for an abscess and she was empirically started on piperacillin–tazobactam. She developed hives on her extremities with associated itching after four days of treatment. Piperacillin–tazobactam was discontinued, diphenhydramine was administered for symptomatic relief, and she was discharged on an oral regimen of ciprofloxacin and metronidazole. She returned the following day with a rash extending onto her chest, abdomen, feet, face, lips and mouth, with newly appeared bullae covering approximately 35–50% of body surface. A skin biopsy was consistent with SJS, with piperacillin–tazobactam identified as the likely causative agent. Conclusion: The most common medications linked to TEN/SJS are sulfonamide antibiotics (especially sulfamethoxazole/trimethoprim), cephalosporins, quinolones, allopurinol, carbamazepine, phenytoin, phenobarbital, and NSAIDs (oxicam­type). While medications the most common cause, mycoplasma pneumoniae and herpes simplex virus (HSV) have also been linked to SJS. The mortality rate of biopsy­ confirmed SJS ranges from 1–5%, whereas the mortality of TEN ranges from 25–35%. Though many patients experience pruritis and/or rashes as side­effects to medications given post­ operatively, it is important to keep in mind more serious reactions such as TEN and SJS as these conditions as they have a substantial associated morbidity and even mortality.