Intussusception of the Appendix: New trends and comprehensive analysis of 140 case reports

INTUSSUSCEPTION OF THE APPENDIX: NEW TRENDS AND COMPREHENSIVE ANALYSIS OF 140 PUBLISHED CASE REPORTS. Barbara A. Wexelman, Cassius Ochoa Chaar, and Walter Longo. Section of Colorectal Surgery, Department of Surgery, Yale University, School of Medicine, New Haven, CT. Statement of Purpose: This paper uses 139 published case reports to understand the demographic, diagnostic, and treatment trends of intussusception of the appendix. Methods: Using the PubMed literature search engine to find all English references of intussusception and appendix, and reviewing those that contained actual case reports of intussusception of the appendix, we analyzed the demographics, presentation, diagnostic methods, surgical treatment, and histology from 140 articles representing data from 181 patients. Results: There were 41 (22.5%) pediatric cases and 141 (77.5%) adult cases. The average age was 37.3 years. There were more males in the pediatric set (23 males to 18 females) while there were more females in the adult set (38 males to 101 females). The most prevalent symptoms in children were abdominal pain (87.8%), vomiting (53.7%), and nausea (26.8%). The adults presented with abdominal pain (75.4%), bloody stools (26.1%), and vomiting (18.1%). Most of the patients reported chronic symptoms (62.6% chronic, 30.8% acute). Barium enema was the most prevalent method for both pediatrics (43.9%) and adults (49.3%). The most common surgical procedure for both the children and the adults was appendectomy (43.9%), followed by right hemicolectomy (20.6%). Prior to 1990 the majority of IA cases were diagnosed intra-operatively (64.8%), but since 2000 over half of the patients (56.8%) were given the correct diagnosis pre-operatively, and less than one third (29.6%) of patients were diagnosed intra-operatively. Endometriosis was the most common histopathology in adult women (37.6%). Conclusions: Adults, especially middle-aged women, make up the majority of patients with intussusception of the appendix. IA should be considered in the workup of chronic abdominal pain in women, and may likely be linked with gastrointestinal endometriosis. Increasingly IA is a pre-operative diagnosis, aided by colonoscopy and CT imaging

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management—American Society of Breast Surgeons Opioid/Pain Control Workgroup

Introduction: The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence. Methods: A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. Results: A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. Conclusions: Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended

Pilot Study to Evaluate Feasibility of Image-Guided Breast-Conserving Therapy in the Advanced Multimodal Image-Guided Operating (AMIGO) Suite

Background. The rate of reexcision in breast-conserving surgery remains high, leading to delay in initiation of adjuvant therapy, increased cost, increased complications, and negative psychological impact to the patient. 1-3 We initiated a phase 1 clinical trial to determine the feasibility of the use of intraoperative magnetic resonance imaging (MRI) to assess margins in the advanced multimodal image-guided operating (AMIGO) suite

Measures of appropriateness and value for breast surgeons and their patients: the american society of breast surgeons choosing wisely (®) initiative

BACKGROUND: Current breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including over-utilization of some tests and operations. To reduce over-utilization, the American Board of Internal Medicine Choosing Wisely (®) Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged. METHODS: The Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely (®) Campaign. The resulting list of appropriateness measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below. RESULTS: (1) Don\u27t routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don\u27t routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don\u27t routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don\u27t routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don\u27t routinely perform a double mastectomy in patients who have a single breast with cancer. CONCLUSIONS: The ASBrS list for the Choosing Wisely (®) campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations