40 Background: Preoperative assessment of the nipple-areolar complex (NAC) is invaluable when considering nipple-sparing mastectomy (NSM). We hypothesized that breast MRI could predict involvement of the NAC with tumor. Methods: We compiled clinical, pathologic and imaging data for patients who underwent preoperative breast MRI followed by mastectomy or NSM between 2006 and 2009. Blinded rereview of all MRI studies was performed by a breast MRI imager and compared to initial MRI findings. Multivariate analysis identified variables predicting NAC involvement with tumor. Results: Of 77 breasts, 18 (23%) had tumor involving or within 1 cm of the NAC. The sensitivity of detecting pathologically confirmed NAC involvement was 61% with history and/or physical exam, and 56% with MRI. Univariate analysis identified the following variables as significant for NAC involvement: large tumors close to the nipple on preoperative MRI, node-positive disease, invasive lobular carcinoma, advanced pathologic T stage, and neoadjuvant chemotherapy. On multivariate analysis, only tumor size > 2 cm and distance to the NAC < 2 cm on MRI maintained significance. Pearson correlation coefficient for MRI size compared to pathologic size was 0.53 (p<0.0001). Conclusions: MRI is not superior to thorough clinical evaluation for predicting tumor in or near the NAC. However, MRI-measured tumor size and distance from the NAC are correlated with increased risk of NAC involvement. Preoperative history and physical examination, tumor characteristics, plus breast MRI can aid the surgeon in planning for successful NSM.
In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.
Routine early postoperative upper gastroesophageal imaging (UGI) is often used in laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures to confirm anastomotic patency and to exclude leaks. The aim of our study was to assess the usefulness of this practice. From January 2003 to November 2004, 322 LRYGB cases were performed using linear staplers for the gastrojejunostomy and jejuno-jejunostomy anastomoses. As part of our protocol, all patients received a Gastrograffin® (Mallinkrodt, Inc., St Louis, Missouri) UGI on postoperative Day 1. The same radiological techniques were used and the same radiological team reviewed all films. Abnormal films were identified. In addition, patient demographics, time to discharge, and complications were collected and analyzed in a prospective database. There were no anastomotic leaks or obstructions. However, 42 of 322 (13%) studies demonstrated delayed gastric emptying. There were no statistically significant differences between patients with normal and delayed UGI studies. Routine UGI studies did not contribute significantly to patient care, and its routine use was subsequently abandoned.
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