Defining the incidence of cutaneous squamous cell carcinoma in coastal NSW Australia

BACKGROUND/OBJECTIVES

To describe the incidence of primary cutaneous squamous cell carcinoma in coastal NSW Australia.

METHODS

The design is a case-controlled study of reported cSCC from 2016 to 2019 within a defined region of coastal southern NSW. Participants include all reported pathological diagnoses of cSCC in patients greater than 20 years of age. The main outcome measures the incidence and relative risk of cSCC.

RESULTS

The overall age-adjusted incidence rate of primary cSCC was 856//year. Men over 60 years of age had an age-adjusted incidence rate of 2875/10⁶ /year. Histologically diagnosed invasive SCC samples were included using SNOMED clinical term codes. Keratoacanthomas and SCC in situ SNOWMED codes were not included. SCC in situ results was found within the sample analysis and was offset by including one SCC per annum per person.

CONCLUSIONS

The rates of cSCC are far higher than previously reported and demand a reappraisal of our national management of this disease.

Diabetes Adversely Influences Postoperative Outcomes After Oesophagectomy: An Analysis of the National Surgical Quality Improvement Program Database

INTRODUCTION

Diabetes is a recognised risk for several chronic and acute illnesses, including increased complications in surgery for oesophageal cancer. Our primary aim is to determine the impact of diabetes on postoperative surgical and medical complications after oesophagectomy.

METHODS

All oesophagectomies for malignancy as reflected in the 2016-2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) datasets were extracted and analysed. Current Procedural Terminology (CPT) codes used were 1) open procedures (43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, and 43123) and 2) hybrid procedures (43186, 43287, and 43288). Logistic regression models examined associations between diabetic status and adverse outcomes. The associations were adjusted for sex, race, age group, operation year, CPT code, body mass index (BMI), smoking, congestive heart failure, antihypertensives, renal failure, and dyspnoea.

RESULTS

Two thousand five hundred and thirty-eight oesophagectomies were identified. 86.45% (n=2,194) underwent open procedures and 13.55% (n=344) had hybrid procedures. There were 177 insulin-dependent diabetics (IDDM) and 320 (12.61%) non-insulin-dependent diabetics (NIDDM). 84.14% were male and 77.74% were Caucasian. 89.48% of the patients were between 50 and 79 years of age. 40.27% experienced postoperative complications. Medical complications (odds ratio [OR]: 1.7, p-value: 0.002), surgical complications (OR: 1.9, p-value: <0.001), wound complications (OR: 2.9, p-value: <0.001), and anastomotic leaks (OR: 2.4, p-value: <0.001) were more common in diabetic patients. Subgroup analysis showed that in hybrid procedures, there is a statistically significant increase in the OR of surgical complications (OR: 3.61, p-value: 0.05), medical complications (OR: 3.76, p-value: 0.04), and anastomotic leak (OR: 3.49, p-value: 0.27) in IDDM as compared to NIDDM.

CONCLUSION

Insulin-dependent diabetes doubles the risk of all major complications compared to nondiabetics. When considering surgical approach and diabetic status (IDDM vs nondiabetics, NIDDM vs nondiabetics), the risk of complications further doubles for hybrid oesophagectomies compared to open procedures.

Synchronous Acute Appendicitis and Cholecystitis in a Paediatric Patient with Salmonella Enteritis

We present the case of a 13-year-old male who presented with right upper quadrant pain and diarrhoea after recently travelling from Bali, Indonesia. He had a normal white cell count of 8x10^9/L and elevated c-reactive protein (CRP) of 205 mg/L with normal liver function tests. Originally thought to be appendicitis, given the rarity of cholecystitis in a child, he was commenced on broad-spectrum antibiotics and was taken to the operating theatre based on his clinical presentation. Diagnostic laparoscopy revealed inflammatory change in both the gallbladder and appendix and a laparoscopic cholecystectomy and appendicectomy were performed simultaneously. Histopathology results confirmed cholecystitis and appendicitis and a stool culture confirmed the presence of Salmonella serotype B. Synchronous cholecystitis and appendicitis is an exceedingly rare phenomenon with only a handful of cases reported in the literature. This is the first case in the literature of this phenomenon occurring in the paediatric population; surgeons need to be aware of this rare possibility even in the paediatric population and especially in those patients with an atypical presentation or in recent travellers experiencing gastroenteritis.

A New Method of Salvaging Breast Reconstruction After Breast Implant Using Negative Pressure Wound Therapy and Instillation

Breast implant infections and their associated inflammatory response can have severe consequences, such as the loss of the prosthesis and cavity, or extensive scarring. Negative pressure wound therapy has been indicated for the management of implant infections. This report describes situations where negative pressure wound therapy was used in conjunction with instillation therapy to treat breast implant infections. The findings showed that the application of these techniques accelerated the treatment of the infections and, most importantly, maintained the breast cavity for future reconstruction.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

An update in breast cancer screening and management

This article provides an overview of the main controversies in a number of key areas of breast cancer management. Relevant studies that have contributed to guide the treatment of this heterogeneous disease in the field of breast screening, surgery, chemotherapy and radiotherapy are highlighted. Mammography and ultrasound are the main methods of breast screening. MRI and tomosynthesis are emerging as new screening tools for a selected group of breast cancer patients. From a surgical perspective, oncoplastic techniques and neoadjuvant chemotherapy are improving cosmetic results in breast-conserving surgery. For high-risk patients, controversies still remain regarding prophylactic mastectomies. Finally, the appropriate management of the axilla continues evolving with the increasing role of radiotherapy as an alternative treatment to axillary dissection.

Infrared evaluation of the heat-sink bipolar diathermy dissection technique

BACKGROUND

The use of the bipolar diathermy dissection technique is widespread amongst surgeons performing flap perforator dissection and microvascular surgery. The 'heat-sink' modification uses a DeBakey forcep as a heat sinking interposition between the bipolar tip and the main (vascular or flap) pedicle aiming to protect it from the thermal effects of the bipolar diathermy. This study examines the thermal effects of bipolar cautery upon the microvasculature and investigates the efficacy of heat sinking as a thermally protective technique in microsurgical dissection.

METHODS

A chicken thigh microsurgical training model was used to examine the effects of bipolar cautery. The effects of bipolar were examined using high definition, real-time infrared thermographic imaging (FLIR Systems) and temperature quantitatively assessed at various distances away from the point of bipolar cautery. Comparison was made using the heat sink technique to determine if it conferred a thermoprotective effect compared to the standard technique without heat sink.

RESULTS

Using paired t-test analysis (SPSS) the heat sink modification of the bipolar dissection technique was found to have a highly statistically significant effect (P < 0.000000001) in reducing the conductive temperature along the vascular pedicle. This protective effect kept temperatures comparable to controls.

CONCLUSION

Bipolar cautery is an extremely safe method of electrosurgery, however when its use is required within 3 mm of important vascular architecture, the heat-sink method is a viable and easy technique to prevent thermal spread and limit potential coagulopathic changes.

A retrospective study to classify surgical indications for infantile hemangiomas

Infantile hemangiomas (IHs) spontaneously involute, but some leave contour deformities necessitating surgical correction. There is a paucity of data reviewing predictive risk factors associated with a need for surgery to guide clinicians when counseling parents. Patients undergoing IH resection by a single surgeon from August 2004 to August 2011 were reviewed to determine patient (age, gender, birth history) and IH characteristics (size, location) associated with surgical intervention. Data were compared to published data from the Hemangioma Investigator Group (HIG). Statistical analysis was performed using Student's t-test, odds ratio, and logistic regression analysis. Out of 196 referred patients, 112 underwent surgery. There was a female preponderance (3.5:1). Two-thirds of patients (64.9%) first presented to the surgeon at ≤2 years of age, but most underwent surgery between 2 and 3 years (52.7%; average lag time, 11 months). 18 patients underwent surgery at ≤1 year of age. IH patients with preterm birth history had increased risk for needing surgical intervention (odds ratio 2.124, CI 1.31-3.44; p < 0.0012). A majority (84.7%) of resected IHs were located on the head or neck, significantly higher than the distribution from the HIG data (62.2%; p < 0.0001). Resected head and neck IHs were smaller than those below the neck (average, 8.85 cm(2) vs. 22.35 cm(2), p = 0.017). Preterm birth is associated with higher risk for requiring surgical intervention. IHs on the head and neck are more likely to be removed when compared to those below the neck, and at a smaller size threshold.