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Nguyen CL, Cui R, Zhou M, Ali F, Easwaralingam N, Chan B, Graham S, Azimi F, Mak C, Warrier S. ASO Visual Abstract: Cost-Effectiveness of Radar Localization Versus Wire Localization for Wide Local Excision of Non-palpable Breast Cancer. Ann Surg Oncol 2024; 31:4545-4546. [PMID: 38722423 DOI: 10.1245/s10434-024-15383-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
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Nguyen CL, Cui R, Zhou M, Ali F, Easwaralingam N, Chan B, Graham S, Azimi F, Mak C, Warrier S. Cost-Effectiveness of Radar Localisation Versus Wire Localisation for Wide Local Excision of Non-palpable Breast Cancer. Ann Surg Oncol 2024; 31:3916-3925. [PMID: 38472677 PMCID: PMC11076345 DOI: 10.1245/s10434-024-15142-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Wire localisation (WL) is the "gold standard" localisation technique for wide local excision (WLE) of non-palpable breast lesions but has disadvantages that have led to the development of wireless techniques. This study compared the cost-effectiveness of radar localisation (RL) to WL. METHODS This was a single-institution study of 110 prospective patients with early-stage breast cancer undergoing WLE using RL with the SCOUT® Surgical Guidance System (2021-2023) compared with a cohort of 110 patients using WL. Margin status, re-excision rates, and surgery delays associated with preoperative localisation were compared. Costs from a third-party payer perspective in Australian dollars (AUD$) calculated by using microcosting, break-even point, and cost-utility analyses. RESULTS A total of 110 WLEs using RL cost a total of AUD$402,281, in addition to the device cost of AUD$77,150. The average additional cost of a surgery delay was AUD$2318. Use of RL reduced the surgery delay rate by 10% (p = 0.029), preventing 11 delays with cost savings of AUD$25,496. No differences were identified in positive margin rates (RL: 11.8% vs. WL: 17.3%, p = 0.25) or re-excision rates (RL: 14.5% vs. WL: 21.8%, p = 0.221). In total, 290 RL cases are needed to break even. The cost of WLE using RL was greater than WL by AUD$567. There was a greater clinical benefit of 1.15 quality-adjusted life-years (QALYs) and an incremental cost-utility ratio of AUD$493 per QALY favouring RL. CONCLUSIONS Routine use of RL was a more cost-effective intervention than WL. Close to 300 RL cases are likely needed to be performed to recover costs of the medical device. CLINICAL TRIAL REGISTRATION ACTRN12624000068561.
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Hailstone L, Tovmassian D, Nguyen CL, Wong P, Le Page PA, Martin D, Taylor C. Medium-Term Outcomes from a Series of 1000 One Anastomosis Gastric Bypass in Australia: A Case Series. Obes Surg 2024; 34:2111-2115. [PMID: 38609707 PMCID: PMC11127843 DOI: 10.1007/s11695-024-07213-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE This study presents the short- (less than 6 months) and medium-term (6 months to 2 years) outcomes for weight loss and type 2 diabetes mellitus (T2DM) for all patients undergoing one anastomosis gastric bypass (OAGB) across multiple institutions between 2015 and 2021. MATERIALS AND METHODS A retrospective analysis of prospectively collected databases was performed including 1022 participants who underwent OAGB at multiple institutions by multiple surgeons between 2015 and 2021. Primary outcome was percentage total weight loss (TWL) and secondary outcomes were achieving resolution of T2DM; OAGB specific short- and medium-term complications including bile reflux, marginal ulceration and internal herniation. RESULTS One thousand and twenty-two patients underwent OAGB (81% primary surgery). A percentage of 34.1% (n = 349) had a preoperative diagnosis of type 2 diabetes mellitus (T2DM). Mean TWL was 33.6 ± 9% with a T2DM remission rate of 74% at 1-year post-op. Rates of bile reflux and marginal ulceration was 1.1% (n = 11) and 1.1% (n = 11). There were no cases of internal herniation during the follow-up period. CONCLUSION OAGB results has echoed previously published work as being efficacious and safe in a short-medium term. The prevalence of complications, especially bile reflux is overall low in our population and no current evidence exists to support an increased risk of metaplasia or malignancy related to bile within the stomach.
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Easwaralingam N, Nguyen CL, Ali F, Chan B, Graham S, Azimi F, Mak C, Warrier S. Radar localization of breast and axillary lesions with SCOUT: a prospective single institution pilot study. ANZ J Surg 2024; 94:1083-1089. [PMID: 38741456 DOI: 10.1111/ans.19022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 04/06/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Wire-guided localization has been the mainstay of localization techniques for non-palpable breast and axillary lesions prior to excision. Evidence is still growing for relatively newer localization technologies. This study evaluated the efficacy of the wireless localization technology, SCOUT®, for both breast and axillary surgery. METHODS Data were extracted from a prospective database (2021-2023) of consecutive patients undergoing wide local excision, excisional biopsy, targeted axillary dissection, or axillary lymph node dissection with SCOUT at a high-volume tertiary centre. Rates of successful reflector placement, intraoperative lesion localization, and reflector retrieval were evaluated. A survey of surgeon-reported ease of lesion localization and reflector retrieval was also evaluated. CLINICAL TRIAL REGISTRATION ACTRN386751. RESULTS One-hundred-ninety-five reflectors were deployed in 172 patients. Median interval between deployment and surgery was 3 days (range 1-20) and mean distance from reflector to lesion was 3.2 mm (standard deviation, SD 3.1). Rate of successful localization and reflector retrieval was 100% for both breast and axillary procedures. Mean operating time was 65.8 min (SD 33). None of the reflectors migrated. No reflector deployment or localization-related complications occurred. Ninety-eight percent of surgeons were satisfied with ease of localization for the first half of cases. CONCLUSION SCOUT is an accurate and reliable method to localize and excise both breast and axillary lesions, and it may overcome some of the limitations of wire-guided localization.
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Nguyen CL, Tovmassian D, Isaacs A, Falk GL. Risk of lymph node metastasis in T1 esophageal adenocarcinoma: a meta-analysis. Dis Esophagus 2024; 37:doae012. [PMID: 38391209 DOI: 10.1093/dote/doae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/29/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
Patients with early (T1) esophageal adenocarcinoma (EAC) are increasingly having definitive local therapy endoscopically. Endoscopic resection is not able to pathologically stage or treat lymph node metastasis (LNM). Accurate identification of patients having nodal metastasis is critical to select endoscopic therapy over surgery. This study aimed to define the risk of LNM in T1 EAC. A meta-analysis of studies of patients who underwent surgery and lymphadenectomy with assessment of LNM was performed according to PRISMA. Main outcome was probability of LNM in T1a and T1b disease. Secondary outcomes were risk factors for LNM and rate of LNM in submucosal T1b (SM1, SM2, and SM3) disease. Registered with PROSPERO (CRD42022341794). Twenty cohort studies involving 2264 patients with T1 EAC met inclusion criteria: T1a (857 patients) with 36 (4.2%) node positive and T1b (1407 patients) with 327 (23.2%) node positive. Subgroup analysis of T1b lesions was available in 10 studies (405 patients). Node positivity for SM1, SM2, and SM3 was 16.3%, 16.2%, and 29.4%, respectively. T1 substage (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.45-13.38, P < 0.01), tumor differentiation (OR 2.82, 95% CI 2.06-3.87, P < 0.01), and lymphovascular invasion (OR 13.65, 95% CI 6.06-30.73, P < 0.01) were associated with LNM. T1a disease demonstrated a 4.2% nodal metastasis rate and T1b disease a rate of 23.2%. Endoscopic therapy should be reserved for T1a disease and perhaps select T1b disease, which has a moderately high rate of nodal metastasis. There were inadequate data to stratify T1b SM disease into 'low-risk' and 'high-risk' based on tumor differentiation and lymphovascular invasion.
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Lau BHT, Kim TJ, Nguyen CL, Hong JSY. Acute transverse colon volvulus: 'double coffee bean' sign. ANZ J Surg 2024; 94:765-766. [PMID: 38345192 DOI: 10.1111/ans.18897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/17/2024] [Accepted: 01/23/2024] [Indexed: 04/17/2024]
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Gooley S, Falk GL. Durability of radiofrequency ablation for long-segment and ultralong-segment Barrett's esophagus over 10 years. Surg Endosc 2024; 38:1239-1248. [PMID: 38092973 DOI: 10.1007/s00464-023-10608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/17/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Long-term durability data for radiofrequency ablation (RFA) to prevent esophageal adenocarcinoma in long-segment (LSBE) and ultralong-segment Barrett's esophagus (ULSBE) is lacking. This study aimed to determine 10-year cancer progression, eradication, and complication rates in LSBE and ULSBE patients treated with RFA. METHODS Single-surgeon prospective database of patients with LSBE (≥ 3 to < 8 cm) and ULSBE (≥ 8 cm) who underwent RFA (2001-2021) were retrospectively analyzed. Ten-year cancer progression calculated with Kaplan-Meier analysis. Eradication rates, including complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), and rates of recurrence and complications, compared between LSBE and ULSBE groups. RESULTS Ten years after starting treatment, the cancer rate was 14.3% in 56 patients. CR-D and CR-IM rates were 87.5% and 67.9%, respectively. Relapse rates from CR-D were 1.8% and 3.6% from CR-IM. Eradication rates for dysplasia in LSBE and ULSBE patients (90.6% versus 83.3%) and IM (71.9% versus 62.5%) were not significantly different. ULSBE patients required higher mean number of ablation sessions for IM eradication (4.7 versus 3.7, p = 0.032), while complication rates including strictures (4.2% versus 6.2%), perforation (0 versus 0), and bleeding (4.2% versus 3.1%), were similar between ULSBE and LSBE patients, respectively. On multivariate analysis, shorter Barrett's segment and baseline low-grade dysplasia were associated with increased likelihood for eradication of IM and dysplasia. A total number of ablation sessions or endoscopic resections ≥ 3 was associated with reduced likelihood for eradication. CONCLUSION RFA was durable in maintaining dysplasia and IM eradication in both LSBE and ULSBE over 10 years, and with low complication rates. IM eradication was more difficult to achieve in ULSBE. Late development of cancer occurred in 14.3%.
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Nguyen CL, Dayaratna N, Graham S, Azimi F, Mak C, Pulitano C, Warrier S. Evolution of Indocyanine Green Fluorescence in Breast and Axilla Surgery: An Australasian Experience. Life (Basel) 2024; 14:135. [PMID: 38255750 PMCID: PMC10821188 DOI: 10.3390/life14010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/05/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing future research evaluating its use for predicting mastectomy skin flap perfusion for reconstruction, lymphatic mapping for sentinel lymph node (SLN) biopsy, and axillary reverse mapping (ARM) for prevention of lymphoedema. In the authors' experience, routine use of ICG angiography during breast reconstruction postmastectomy was demonstrated to be cost-effective for the reduction of ischemic complications in the Australian setting. A novel tracer combination, ICG-technetium-99m offered a safe and effective substitute to the "gold standard" dual tracer for SLN biopsy, although greater costs were associated with ICG. An ongoing trial will evaluate ARM node identification using ICG fluorescence during axillary lymph node dissection and potential predictive factors of ARM node involvement. These data add to the growing literature on ICG and allow future research to build on this to improve understanding of the potential benefits of fluorescence-guided surgery in breast cancer and reconstruction surgery.
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Isaacs A, Gooley S, Falk GL. Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases. J Gastrointest Surg 2023; 27:2733-2742. [PMID: 37962716 PMCID: PMC10837213 DOI: 10.1007/s11605-023-05856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence. METHOD Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. RESULTS Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively). CONCLUSION Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.
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Nguyen CL, Tovmassian D, Isaacs A, Gooley S, Falk GL. Trends in outcomes of 862 giant hiatus hernia repairs over 30 years. Hernia 2023; 27:1543-1553. [PMID: 37650983 PMCID: PMC10700453 DOI: 10.1007/s10029-023-02873-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years. METHODS Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into "composite repair" (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991-2002; Group 2, 2003-2012; Group 3, 2012-2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis. RESULTS 862 giant PEH repairs met selection criteria. There was an increasing proportion of "composite repair" after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study's end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien-Dindo grade ≥ III complications including two perioperative deaths (0.2%). CONCLUSION Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of "composite repair", supporting the possible improvement in recurrence rates with this approach.
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Nguyen CL, Zhou M, Easwaralingam N, Seah JL, Azimi F, Mak C, Pulitano C, Warrier SK. ASO Author Reflections: Indocyanine Green Fluorescence Sentinel Lymph Node Biopsy in Breast Cancer-An Alternative to Blue Dye? Ann Surg Oncol 2023; 30:6528-6529. [PMID: 37474695 PMCID: PMC10506918 DOI: 10.1245/s10434-023-13951-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
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Nguyen CL, Zhou M, Easwaralingam N, Seah JL, Azimi F, Mak C, Pulitano C, Warrier S. Novel Dual Tracer Indocyanine Green and Radioisotope Versus Gold Standard Sentinel Lymph Node Biopsy in Breast Cancer: The GREENORBLUE Trial. Ann Surg Oncol 2023; 30:6520-6527. [PMID: 37402976 PMCID: PMC10507001 DOI: 10.1245/s10434-023-13824-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/14/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND The methods for sentinel lymph node (SLN) biopsy in breast cancer have been variable in type and number of tracers. Some units have abandoned the use of blue dye (BD) due to adverse reactions. Fluorescence-guided biopsy with indocyanine green (ICG) is a relatively novel technique. This study compared the clinical efficacy and costs between novel dual tracer ICG and radioisotope (ICG-RI) with "gold standard" BD and radioisotope (BD-RI). METHODS Single-surgeon study of 150 prospective patients with early breast cancer undergoing SLN biopsy (2021-2022) using ICG-RI compared with a retrospective cohort of 150 consecutive previous patients using BD-RI. Number of SLNs identified, rate of failed mapping, identification of metastatic SLNs, and adverse reactions were compared between techniques. Cost-minimisation analysis performed by using Medicare item numbers and micro-costing analysis. RESULTS Total number of SLNs identified with ICG-RI and BD-RI was 351 and 315, respectively. Mean number of SLNs identified with ICG-RI and BD-RI was 2.3 (standard deviation [SD] 1.4) and 2.1 (SD 1.1), respectively (p = 0.156). There were no cases of failed mapping with either dual technique. Metastatic SLNs were identified in 38 (25.3%) ICG-RI patients compared with 30 (20%) BD-RI patients (p = 0.641). There were no adverse reactions to ICG, whereas four cases of skin tattooing and anaphylaxis were associated with BD (p = 0.131). ICG-RI cost an additional AU$197.38 per case in addition to the initial cost for the imaging system. CLINICAL TRIAL REGISTRATION ACTRN12621001033831. CONCLUSIONS Novel tracer combination, ICG-RI, provided an effective and safe alternative to "gold standard" dual tracer. The caveat was the significantly greater costs associated with ICG.
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Nguyen CL, Zhou M, Easwaralingam N, Seah JL, Azimi F, Mak C, Pulitano C, Warrier SK. ASO Visual Abstract: Novel Dual Tracer Indocyanine Green and Radioisotope Versus Gold Standard Sentinel Lymph Node Biopsy in Breast Cancer-The GREENORBLUE Trial. Ann Surg Oncol 2023; 30:6530-6531. [PMID: 37501050 DOI: 10.1245/s10434-023-13997-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
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Rajendran S, Nguyen CL, Brown KGM, Solomon MJ. The evolution of oncovascular pelvic surgery: A historical perspective. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1314-1316. [PMID: 36690534 DOI: 10.1016/j.ejso.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Pelvic exenteration surgery has evolved dramatically in recent decades and now represents the standard of care for many patients with advanced pelvic malignancy. Most recently the use of complex vascular resection and reconstructive techniques have been applied in advanced pelvic oncology surgery at specialist units and these oncovascular techniques are considered one of the frontiers in this field. This article summaries the historical evolution of oncovascular surgery in the pelvis and sets the scene for where this treatment is going. The role of vascular resection and reconstruction in curative treatment of advanced pelvic malignancy is an evolving area that is redefining the boundaries of what was historically thought possible.
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Rajendran S, Nguyen CL, Brown KGM, Solomon MJ. Clinical algorithm for the management of advanced pelvic tumours involving the aortoiliac axis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1317-1319. [PMID: 36964055 DOI: 10.1016/j.ejso.2023.03.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 03/13/2023]
Abstract
Pelvic exenteration offers potentially curative treatment for locally advanced and recurrent pelvic tumours. Laterally infiltrating tumours involving the pelvic sidewall have historically been considered unresectable. Highly specialised exenteration units have accumulated experience with en bloc resection of part or all of the iliac vascular system for tumours with major vessel involvement. These approaches involve complex vascular dissection and reconstructive techniques requiring collaboration with the vascular surgery unit. Adding to the complexity is the paucity of evidence on oncovascular techniques in the pelvis given its developing nature. An algorithm for the workup to determine resectability and the vascular reconstruction approach for advanced pelvic tumours involving the aortoiliac axis is suggested based on current literature and personal experience from the authors' unit.
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Dayaratna N, Nguyen CL, Yalarmathi N, Spillane A, Mak C, Warrier S, Dusseldorp JR. Trends And Variations In Post-Mastectomy Breast Reconstruction Rates In Australia Over 10 Years. Breast 2023. [DOI: 10.1016/j.breast.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
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Dayaratna N, Nguyen CL, Spillane A, Mak C, Warrier SK, Dusseldorp JR. Trends and variations in post-mastectomy breast reconstruction rates in Australia over 10 years. ANZ J Surg 2023; 93:242-250. [PMID: 36651629 DOI: 10.1111/ans.18243] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Offering breast reconstruction (BR) at the time of mastectomy is standard of care in Australia with proven quality-of-life benefits. Previously BR rates in Australia have been low compared to similar countries. Accurate up-to-date information is needed to promote equity in access to BR and inform future planning of services. This study analysed recent trends and variations of BR uptake in Australia. METHOD Data from the BreastSurgANZ Quality Audit (BQA) were used to identify patients who underwent mastectomy with or without reconstruction for invasive or in situ breast carcinoma from 2010 to 2019. The association between BR uptake and the variables of jurisdiction (state or territory), age, hospital type and remoteness, and remoteness of patients' home addresses were analysed. RESULTS A total 41 880 women underwent mastectomy between 2010 to 2019. The national BR rate steadily increased from 12.8% in 2010 to 29% in 2019, with a 10-year national average of 21.3%. Statistically significant differences in BR uptake (P < 0.001) were found between states with higher rates in New South Wales and Victoria, with BR more likely in private hospitals and in younger women (P < 0.001), and less likely in remote areas (P < 0.001). CONCLUSION The Australian BR rate has increased over the 10-year period, but significant variation still exists between states. BR is lower in older women and those living in regional and remote areas. While the steady increase in BR uptake is encouraging, barriers that exist to equitable provision of reconstructive surgical services for all women living with breast cancer still need to be corrected.
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Nguyen CL, Comerford AP, Dayaratna N, Lata T, Paredes SR, Easwaralingam N, Seah JL, Azimi F, Mak C, Pulitano C, Warrier SK. Trends in outcomes with adoption of indocyanine green angiography in postmastectomy reconstruction. ANZ J Surg 2023; 93:270-275. [PMID: 36576103 DOI: 10.1111/ans.18241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Indocyanine green angiography (ICGA) aims to reduce ischaemic complications by supplementing intraoperative perfusion assessment of mastectomy flaps. Learning curves for this technology have not been analysed. We evaluated changes in patient outcomes with increasing case volume after ICGA adoption in postmastectomy reconstruction. METHODS Single-institution retrospective analysis of 320 implant-based reconstructions following mastectomy using ICGA from 2015, when it was introduced, to 2021. Cases chronologically divided into tertiles and complications amongst groups evaluated. Trends in ischaemic complications plotted using weighted moving average. CUSUM analysis determined after how many cases plateau was reached. Number of ischaemic complications prior to plateau calculated with AUC analysis. RESULTS Ischaemic complications decreased over time (Group 1, 15.1%; Group 2, 11.2%; Group 3, 4.7%, P = 0.034). Cases of delayed reconstruction increased over time (Group 1, 6.6%; Group 2, 28%; Group 3, 22.4%; P < 0.001). Our institution reached plateau of 10% ischaemic complications after 160 cases. Mean incidence of ischaemic complications decreased from 16.9% during the first 160 cases to 3.8% after plateau was reached (P < 0.001). Eleven extra breasts (6.9%) experienced ischaemic complications, that may have been avoided if operated by surgeons after the first 160 cases. CONCLUSIONS There was increased tendency towards a conservative approach of delaying reconstruction and decreased rates of ischaemic complications with increasing case volume after ICGA implementation. A significant number of cases were needed to reach plateau of minimal ischaemic complications. This data could encourage development of standardized protocols for this technology to shorten learning curves for improved patient outcomes.
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Nguyen CL, Tovmassian D, Isaacs A, Le Page P, Falk GL. Diaphragmatic eventration complicated by gastric volvulus. ANZ J Surg 2022; 93:1064-1066. [PMID: 36196995 DOI: 10.1111/ans.18103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/10/2022] [Accepted: 09/24/2022] [Indexed: 11/28/2022]
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Nguyen CL, Tam SKM, Easwaralingam N, Seah JL, Comerford AP, Yu ACX, Mak C, Pulitano C, Warrier SK. Patterns of ischaemia and reperfusion in nipple-sparing mastectomy reconstruction with indocyanine green angiography. J Plast Reconstr Aesthet Surg 2022; 75:4144-4151. [DOI: 10.1016/j.bjps.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 05/02/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
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Nguyen CL, Dayaratna N, Comerford AP, Tam SKM, Paredes SR, Easwaralingam N, Seah JL, Azimi F, Mak C, Pulitano C, Warrier SK. Cost-effectiveness of indocyanine green angiography in postmastectomy breast reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:3014-3021. [PMID: 35710777 DOI: 10.1016/j.bjps.2022.04.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/19/2022] [Accepted: 04/12/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Mastectomy skin flap necrosis is a major complication of skin- or nipple-sparing mastectomy. Indocyanine green angiography (ICGA) is a novel technology that can identify flaps at risk of necrosis, but there is paucity of cost-effectiveness data particularly in the Australian context. We evaluated its cost-effectiveness in breast reconstruction surgery. METHODS Single-institution retrospective study of 295 implant-based breast reconstructions using ICGA compared with 228 reconstructions without ICGA from 2015 to 2020. Costs were calculated using Medicare item numbers and micro-costing analysis. Break-even point analysis determined the number needed to break-even. Cost-utility analysis compared probabilities of ischaemic complications and utility estimates derived from surveys of surgeons to fit into a decision model. RESULTS There were 295 breast reconstructions using ICGA with a total cost of AU$164,657. The average cost of treating an ischaemic complication was AU$21,375. Use of ICGA reduced the ischaemic complication rate from 14.9% to 8.8%. Ischaemic complications were prevented in 18 breasts resulting in gross cost savings of AU$384,745 and net savings of AU$220,088. Three hundred eighteen cases using ICGA are needed to break-even. The decision model demonstrated a baseline cost difference of AU$1,179, a quality-adjusted life-years (QALY) difference of 1.77, and an incremental cost-utility ratio (ICUR) of AU$656 per QALY favouring ICGA. CONCLUSIONS Routine use of ICGA during implant-based breast reconstruction is a cost-effective intervention for the reduction of ischaemic complications in the Australian setting. ICGA use was associated with a gain of 1.77 additional years of perfect health at a cost of AU$656 more per year.
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Nguyen CL, Barry N, Lindsay A, Seah JL, Easwaralingam N, Pulitano C, Warrier S. Indocyanine green angiography in breast reconstruction surgery: A systematic review of cost-analysis studies. J Plast Reconstr Aesthet Surg 2021; 74:3196-3211. [PMID: 34607780 DOI: 10.1016/j.bjps.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/05/2021] [Accepted: 08/26/2021] [Indexed: 11/19/2022]
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Gillies MC, Nguyen CL, Nguyen V, Daien V, Cohn A, Banerjee G, Arnold J. Reply. Ophthalmology 2020; 127:e21-e22. [DOI: 10.1016/j.ophtha.2019.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022] Open
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Nguyen CL, Lindsay A, McLachlan R, Islam S, Qasabian R, Loa J. Aortoduodenal fistula 2 years after elective endovascular repair of an abdominal aortic aneurysm. ANZ J Surg 2020; 90:2374-2376. [DOI: 10.1111/ans.15773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/21/2022]
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Nguyen CL, van Dijk A, Smith G, Leibman S, Mittal A, Albania M, de Reuver P, Hugh TJ. Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters. ANZ J Surg 2019; 90:295-299. [PMID: 31845500 DOI: 10.1111/ans.15603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/21/2019] [Accepted: 11/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same-admission or delayed LC. METHODS Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12-month period was conducted. RESULTS A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post-operative length of stay and more complications compared with those who had non-AC diagnosis. There was no difference in outcomes between same-admission LC or delayed LC. CONCLUSION TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same-admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC.
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