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Poruk KE, Hicks CW, Trent Magruder J, Rodriguez-Unda N, Burce KK, Azoury SC, Cornell P, Cooney CM, Eckhauser FE. Creation of a novel risk score for surgical site infection and occurrence after ventral hernia repair. Hernia 2016; 21:261-269. [PMID: 27990572 DOI: 10.1007/s10029-016-1547-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 11/12/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Complex ventral hernia repair (VHR) is a common surgical operation but carries a risk of complications from surgical site infections (SSI) and occurrences (SSO). We aimed to create a predictive risk score to identify patients at increased risk for SSO or SSI within 30 days of surgery. METHODS Data were prospectively collected on all patients undergoing VHR between January 2008 and February 2015 by a single surgeon. Multivariable logistic regression was used to identify independent factors predictive of SSO and SSI. Significant predictors of SSO and SSI were assigned point values based on their odds ratios to create a novel risk score, the Hopkins ventral hernia repair SSO/SSI risk score; predicted and actual rates of outcomes were then compared using weighted regression. RESULTS During the study period, 362 patients underwent open VHR. Thirty-day SSO and SSI occurred in 18.5 and 10% of patients, respectively. After risk adjustment, ASA class ≥3 (1 point), operative time ≥4 h (2 points), and the absence of a postoperative wound vacuum dressing (1 point) were predictive of 30-day SSO. Predicted risk of SSO utilizing this scoring system was 9.7, 19.4, 29.1, and 38.8% for 1, 2, 3, and 4 points (AUC = 0.73). For SSI, operative time ≥4 h (1 point) and the lack of a wound vacuum dressing (1 point) were predictive. Predicted risk of SSI based on this scoring system was 12.5% for 1 point and 25% for 2 points (AUC = 0.71). Actual vs. predicted rates of SSO and SSI correlated strongly for risk model with a coefficient of determination (R 2) of 0.92 and 0.91, respectively. CONCLUSION The novel Hopkins ventral hernia repair risk score accurately predicts risk of SSO and SSI after complex VHR. Further studies using a prospective randomized controlled trial will be needed to further validate our findings.
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Affiliation(s)
- K E Poruk
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - C W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - J Trent Magruder
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - N Rodriguez-Unda
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - K K Burce
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - S C Azoury
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - P Cornell
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - C M Cooney
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - F E Eckhauser
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Hopkins ZH, Frandsen J, Poruk KE, Agarwal J, Poppe MM. Abstract P3-12-08: Are different therapeutic approaches required after skin and nipple sparing mastectomies for locoregional control? A single institution's experience. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p3-12-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction
Nipple sparing (NSM) and skin sparing (SSM) mastectomies are gaining popularity. These procedures leave breast tissue at the skin/breast interface with the intent to better cosmesis. However, the impact of NSM versus SSM on risk of local recurrence in the remaining breast tissue is not well characterized, nor is the effect of post mastectomy radiotherapy (PMRT) in these patients.
Methods
A single institution retrospective study was conducted on women treated with NSM or SSM from 2005 to 2011 with follow up through 2015. Chest wall and chest wall or axillary recurrence were assessed. Factors associated with recurrence were examined. Kaplan Meier estimates and Cox proportional hazards models were used to analyze chest wall recurrence (CWR) and chest wall or axillary recurrence (CWAR), with CWAR as the primary outcome variable.
Results
This analysis identified 181 women who underwent a SSM (n=103, 58 (56%) with PMRT) or NSM (n=78, 35 (45%) with PMRT). Women undergoing SSM were older (56.0 ± 13.6 years, mean ± SD) than NSM (44.6 ± 11.3, p <0.0001) while follow-up times were similar (4.91 ± 0.43 and 5.43 ± 0.27 respectively, p = 0.15). Women undergoing PMRT were younger (49.2 ± 13.6 vs 53.1 ± 13.9 years, p = 0.008) but more likely to present with lymphovascular space invasion (LVSI)(42% vs 16%, p = 0.0003 by Chi-square), and were more likely to receive chemotherapy (83% vs 47%, p <0.0001). The majority of women (62%) in the group not receiving PMRT had stage I disease, and 79% were node negative. For those undergoing PMRT, 83% were stage II or III, and 69% were node positive (p <0.0001 for both differences). Despite the higher apparent risk of the PMRT group, the total number of chest wall or axillary recurrences was similar (8 in PMRT, 6 in no PMRT). Event-free survival for CWAR at 5 years was 92% for PMRT and 96% for no PMRT (p=0.42) and at 7.5 years, 85% and 84% respectively (p=0.42). In univariate Cox regression among all patients, age was the strongest predictor of CWAR (HR = 1.103 per year of age, 95% CI 1.053-1.154, p<0.0001). CWAR occurred in 2.6 % of NSM patients as compared with 11.8% of SSM patients (p=0.025 by Fisher's exact test). SSM versus NSM was associated with increased hazzard for CWAR with HR = 4.6 (95% CI 1.03-21, p=0.046) on univariate analysis. However, this apparent risk became non-significant (HR = 2.24, 95% CI 0.48 – 10.5) with adjustment for age. Other variables associated with CWAR on univariate analysis included receipt of chemotherapy (HR = 0.28, 0.09-0.86, p=0.027) and estrogen receptor positive status (HR = 0.34, 0.12-0.98, p=0.046) but these also became non-significant with adjustment for age. In multivariate Cox regression analysis, use of PMRT was associated with a non-significant higher risk of CWAR (HR = 1.45, 0.33-6.4, p=0.63 ) adjusting for age, LVSI, mastectomy type, stage, and ER status.
Conclusions
The risk of a chest wall or axillary recurrence for early stage breast cancer after a SSM or NSM appears to be low at five years. Radiation can likely be omitted in this group. Furthermore, despite presenting with more advanced disease, women who underwent PMRT experienced excellent locoregional control. Further research is needed on this topic.
Citation Format: Hopkins ZH, Frandsen J, Poruk KE, Agarwal J, Poppe MM. Are different therapeutic approaches required after skin and nipple sparing mastectomies for locoregional control? A single institution's experience. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-08.
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Affiliation(s)
- ZH Hopkins
- Huntsman Cancer Hospital, Salt Lake City, UT; Johns Hopkins Hosptial, Baltimore, MD; University of Utah Hospital, Salt Lake City, UT
| | - J Frandsen
- Huntsman Cancer Hospital, Salt Lake City, UT; Johns Hopkins Hosptial, Baltimore, MD; University of Utah Hospital, Salt Lake City, UT
| | - KE Poruk
- Huntsman Cancer Hospital, Salt Lake City, UT; Johns Hopkins Hosptial, Baltimore, MD; University of Utah Hospital, Salt Lake City, UT
| | - J Agarwal
- Huntsman Cancer Hospital, Salt Lake City, UT; Johns Hopkins Hosptial, Baltimore, MD; University of Utah Hospital, Salt Lake City, UT
| | - MM Poppe
- Huntsman Cancer Hospital, Salt Lake City, UT; Johns Hopkins Hosptial, Baltimore, MD; University of Utah Hospital, Salt Lake City, UT
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Azoury SC, Rodriguez-Unda N, Soares KC, Hicks CW, Baltodano PA, Poruk KE, Hu QL, Cooney CM, Cornell P, Burce K, Eckhauser FE. The effect of TISSEEL fibrin sealant on seroma formation following complex abdominal wall hernia repair: a single institutional review and derived cost analysis. Hernia 2015; 19:935-42. [DOI: 10.1007/s10029-015-1403-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/26/2015] [Indexed: 10/23/2022]
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Poruk KE, Weiss MJ. The current state of surgery for pancreatic cancer. MINERVA GASTROENTERO 2015; 61:101-115. [PMID: 25651834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Pancreatic adenocarcinoma (PDAC) is the fourth leading cause of cancer mortality in the United States, with a dismal 5-year survival of only 6% for all stages. Surgical resection offers the best opportunity for prolonged survival at this time, but is limited to patients with locally resectable tumors and no distant metastases. Although only 10-20% of patients present with early stage disease are amenable to surgical resection, remarkable advancements have been made over the past several decades leading to improved morbidity and mortality after pancreatic resection. This article will review the current state of pancreatic surgery including its role in the multidisciplinary approach to pancreatic cancer treatment, advances and controversies in surgical technique, and the limitations of surgical therapy that will need to be addressed in the future to improve survival for patients with pancreatic cancer.
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Affiliation(s)
- K E Poruk
- Department of Surgery The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA -
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E. Poruk K, Z. Gay D, Brown K, D. Mulvihill J, M. Boucher K, L. Scaife C, A. Firpo M, J. Mulvihill S. The Clinical Utility of CA 19-9 in Pancreatic Adenocarcinoma: Diagnostic and Prognostic Updates. Curr Mol Med 2013. [DOI: 10.2174/156652413805076876] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Chidester JR, Olson JR, Poruk KE, Marengo JJ, Matsen CB, Neumayer L, Agarwal J. P2-16-03: Outcomes of Nipple-Sparing Mastectomy (NSM) and Immediate Reconstruction. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p2-16-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Nipple-sparing mastectomy (NSM) is the surgical removal of breast tissue that preserves the entire skin envelope including the nipple areola skin (NAS). We report our experience performing NSMs and immediate breast reconstruction for both high-risk breast cancer treatment and prophylaxis over a six-year period at The University of Utah and Huntsman Cancer Hospital.
Methods: A retrospective chart review was performed on patients undergoing NSM from April 2005 - April 2011. Data collection included: patient demographics, oncologic details, surgical information (including reconstruction timing and type), and complications (infection, hematoma, seroma, skin necrosis, NAS complication, skin flap loss, premature expander exchange/removal, and capsular contracture).
Results: 130 patients underwent 205 NSMs. Of these, 106 (81.5%) patients received mastectomy treatment for cancer while 24 (18.5%) patients were prophylactically treated. 102 NSMs (49.8%) were on breasts with biopsy-proven cancer, while 103 (50.2%) NSMs were on breasts for prophylaxis. All patients were female with a mean age of 44.7 years (range, 16–82 years). 119 (92.2%) patients were Caucasian, 3 (2.3%) were Asian, and 1 (0.8%) was Hispanic. The mean weight was 65.2 kg (range, 42.8 - 98.8 kg) and BMI (n=106) was 23.7 kg/m2 (SE±0.4). 14 (10.9%) and 12 (9.3%) of the patients were known to have a BRCA1 and BRCA2 mutation, respectively. Two (1.6%) patients had a p53 mutation. 172 (83.5%) of the nipples were spared via an 8 cm incision lateral to the midpoint of the areola, while 5 (2.4%) of the incisions were made along the IMF. The remaining 28 (13.7%) incisions were made by other techniques. 201 (98.0%) breasts were immediately reconstructed with tissue expanders (193 went on to implant reconstruction and 8 underwent autologous tissue reconstruction). 4 (2.0%) breasts received delayed reconstruction. Positive margins were found in 15 (7.3%) of 205 breasts. 60 (58.8%) of 102 cancerous breasts that underwent NSM were Stage 0-I, 35 (34.3%) were Stage II and the remaining 8 (7.8%) were Stage III - IV. Complications by case (Table 1) and by breast (Table 2) are shown below.
Conclusion: When comparing NSMs in both patients and individual breasts with cancer to patients and breasts treated for prophylaxis, there is no significant difference in complication rates by case or breast, except for the capsular contracture rate, which was significantly higher in breasts treated for cancer. Overall, complication rates are low in both cases of cancer and prophylaxis; this demonstrates that NSM and immediate reconstruction is a highly effective method of treatment for both groups.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-03.
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Affiliation(s)
- JR Chidester
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
| | - JR Olson
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
| | - KE Poruk
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
| | - JJ Marengo
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
| | - CB Matsen
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
| | - L Neumayer
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
| | - J Agarwal
- 1Loma Linda University Medical Center, Loma Linda, CA; University of Utah School of Medicine, Salt Lake City, UT
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