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Minimal invasive surgical technique has been increasingly applied to breast surgery. Since the first robot-assisted nipple-sparing mastectomy was introduced, we have been performing nipple-sparing mastectomy using multi-port robotic surgical system. Last year, the new robotic surgical system with single port was introduced. We report the development of a robotic nipple-sparing mastectomy with immediate reconstruction through a single incision using the updated single-port surgical robot system for a patient with ductal carcinoma in situ (DCIS). Breast reconstruction was performed using implants. Postoperative pathological examination revealed DCIS in both breasts. There were no major immediate complications, except for a minor skin burn on the right breast. Overall, the initial operation using the updated platform was safely performed.

PurposePredicting the need for surgical intervention among patients with intestinal obstruction is challenging. The delta neutrophil index (DNI) has been suggested as a useful marker of immature granulocytes, which indicate an infection or sepsis. In this study, we evaluated the impact of the DNI as an early predictor of operation among patients with intestinal obstruction.MethodsA total of 171 patients who were diagnosed with postoperative intestinal obstruction were enrolled in this study. Medical records, including data for the initial CRP level, WBC count, and DNI were reviewed. Receiver operating characteristic (ROC) curves were generated to clarify the optimal DNI cutoff values for predicting an operation.ResultsAmong the 171 patients, 38 (22.2%) needed surgical intervention. The areas under the initial CRP, WBC, and DNI ROC curves were 0.460, 0.449, and 0.543, respectively. The optimal cutoff value for predicting further surgical intervention according to the initial DNI level was 4.3%. The accuracy of the cutoff value was 74.9%, the sensitivity was 23.7%, and the specificity was 89.5% (positive predictive value, 23.7%; negative predictive value, 89.5%). In the multivariate analysis, initial DNI levels ≥ 4.3% were significantly associated with surgical intervention (odd ratio, 3.092; 95% confidence interval, 1.072–8.918; P = 0.037).ConclusionThe initial DNI level in patients with intestinal obstruction may be a useful predictor for determining the need for surgical intervention.

PurposeThis study is to directly compare surgical outcomes between conventional nipple-sparing mastectomy (CNSM) and robot-assisted nipple-sparing mastectomy (RNSM).Materials and MethodFor this case–control study, 369 cases of 333 patients who underwent CNSM or RNSM with immediate reconstruction between November 2016 and January 2019 at Severance Hospital in Seoul, Republic of Korea were reviewed. Patients with stage IV breast cancer (n = 1), receiving neoadjuvant chemotherapy (n = 43), or subjected to previous operations (n = 14) or radiotherapy on the breasts were excluded. The main outcomes were comparing rates of post-operative complications, of high-grade post-operative complications as defined by the Clavien-Dindo classification, and nipple necrosis between the CNSM and the RNSM groups.ResultsA total of 311 cases, including 270 CNSMs and 41 RNSMs, were analyzed. The rates of post-operative nipple necrosis (p = 0.026, 2.4 vs. 15.2%) and of high-grade post-operative complications (p = 0.031, 34.8 vs. 17.1%) in the RNSM group were significantly lower than those in the CNSM group.ConclusionRNSM was associated with lower rates of high-grade post-operative complications and nipple necrosis than CNSM for patients with small breast volumes and less ptotic breasts.

Robotic surgical systems are used in various surgeries. 1 They can enhance a surgeon's performance during surgery by providing a highresolution three-dimensional camera and highly flexible robotic arms. Robotic-assisted nipple-sparing mastectomy (RNSM) was first

Purpose: To validate and update a nomogram for predicting ductal carcinoma in situ (DCIS) upstaging in preoperative biopsy. Materials and Methods: Medical records of 444 preoperative DCIS patients were evaluated and used to validate a previous version of the Severance nomogram for predicting DCIS upstaging in preoperative biopsy. Patients were divided into two groups according to the final postoperative pathology. Univariate and multivariate analyses with the chi-square test, Student's t-test, and binary logistic regression method identified new significant variables. The updated nomogram was evaluated with the C-index and Hosmer-Lemeshow goodness of fit test. Results: The area under a receiver operating characteristic curve for comparison with the previous nomogram was 0.48. In postoperative pathology, the pure DCIS and invasive cancer groups comprised 345 and 99 cases, respectively. Approximately 22.3% of patients preoperatively diagnosed with DCIS were upstaged to invasive cancer. Significant variables in the univariate analysis were operation type, human epidermal growth factor receptor 2 overexpression, comedo necrosis, sonographic mass, mammographic mass, preoperative biopsy method, and suspicious microinvasion in preoperative biopsy. In multivariate analysis, operation type, sonographic mass, mammographic mass, and suspicious microinvasion were risk factors for upstaging. The updated model with these variables showed moderate discrimination and was appropriate in the calibration test. Conclusion: The previous nomogram did not effectively discriminate upstaging of preoperative DCIS in an independent cohort. An updated version of the nomogram appears to provide more accurate information for predicting preoperative DCIS upstaging.

Purpose Nipple-sparing mastectomy (NSM) includes various techniques, including conventional or endoscopic mastectomies. Since the introduction of robot-assisted NSM (RANSM) in 2015, 2 main methods have been used: gasless and gas-inflated techniques. The aim of this study was to compare clinicopathologic characteristics, surgical outcomes, and postoperative complications between patients treated with gasless RANSM and those treated with gas-inflated RANSM. Methods We conducted a retrospective study of women who underwent gasless or gas-inflated RANSM with immediate breast reconstruction between November 2016 and May 2019. The indications for RANSM were early breast cancer, interstitial mastopathy, or BRCA 1/2 mutation carriers. Clinicopathologic characteristics, surgical outcomes, and postoperative complications were analyzed. The severity of complications was graded using the Clavien-Dindo system. Results A total of 58 RANSM procedures were performed in 46 women: 15 cases of gasless RANSM and 43 cases of gas-inflated RANSM. The proportion of node-negative disease was higher in the gas-inflated group (97.1%) than in the gasless group (69.2%, p = 0.016). Adjuvant radiotherapy was administered in 30.6% of the cases in the gasless group and only 5% of the cases in the gas-inflated group. Other clinicopathological factors were not significantly different between the groups. Regarding surgical outcomes, the initial incision was 1 cm longer in the gasless group (5.17 ± 0.88 cm) than that in the gas-inflated group (4.20 ± 1.05 cm; p = 0.002). The final incision was also longer in the gasless group (5.17 ± 0.88 cm) than that in the gas-inflated group (4.57 ± 1.07 cm; p = 0.040). Operation time, complication rate, and complication grade were not significantly different between the 2 groups. Conclusion In this study, there were no significant differences in surgical outcomes or postoperative complications between gasless and gas-inflated RANSM, except for a longer incision with the gasless technique. Both techniques are reasonable options for RANSM followed by immediate reconstruction.

There is a potential risk that lobular carcinoma in situ (LCIS) on preoperative biopsy might be diagnosed as ductal carcinoma in situ (DCIS) or invasive carcinoma in the final pathology. This study aimed to evaluate the rate of upgrade of LCIS on preoperative biopsy to DCIS or invasive carcinoma. Materials and MethodsData of 55 patients with LCIS on preoperative biopsy were analyzed. All patients underwent surgery between 1991 and 2016 at Severance Hospital in Seoul, Korea. We analyzed the rate of upgrade of preoperative LCIS to DCIS or invasive cancer in the final pathology. The clinicopathologic features related to the upgrade were evaluated. ResultsThe rate of upgrade of LCIS to DCIS or invasive carcinoma was 16.4% (9/55). In multivariate analysis, microcalcification and progesterone receptor expression were significantly associated with the upgrade of LCIS (p=0.023 and 0.044, respectively). ConclusionThe current study showed a relatively high rate of upgrade of LCIS on preoperative biopsy to DCIS or invasive cancer. The presence of microcalcification and progesterone receptor expression may be potential predictors of upgradation of LCIS on preoperative biopsy. Surgical excision of the LCIS during preoperative biopsy could be a management option to identify the concealed malignancy.