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Laparoscopic Cholecystectomy (Gallbladder) Customized Circular Cutting Device Lowers Re-excision Rate for Breast Cancer (updated June 2008) Hernias- Recurrence Rates (updated July 2007)
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Dekalb Surgical Associates has implemented a method of continuous outcomes assessment for a variety of clinical indicators. One of these indicators looks at the long-term survival of patients with breast cancer. Overall five year survival for our patients is over 78%. This data has been compared to published data for Georgia from the National Cancer Data Bank, and is shown below, and includes patients from 1985-1991. Also shown is the 5-year survival for all DeKalb Medical Center patients. |
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Data for patients with Stage II breast cancer from 1997-98 shows similar results for this sub-group. This is the most recent data available for looking at 5-year survival rates. National comparison data for this time period is not yet available, so the national data shown (NCDB, which stands for “National Cancer Data Base”) is from 1995-96. The other comparison is with all other Stage II breast cancer patients treated at Dekalb Medical Center during the 1997-98 time period. The 5-year survival for our patients is 87% compared with 80% for all other patients at DeKalb Medical Center.
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Survival for patients with colon cancer is another important indicator which we monitor. For patients at DeKalb Surgical Associates, the overall 5 year observed survival rate is over 63%. In the past, all patients undergoing surgery for removal of a colon cancer had to go through a bowel cleansing, just like they have for a colonoscopy. But more recent studies have shown that this is often unnecessary. Most patients can be discharged from the hospital within about five days, and sometimes even less. Patients usually are allowed liquids even in the evening following surgery. Laparoscopic techniques are often utilized, depending on the location and size of the cancer. Very few colon cancer patients require a colostomy with current surgical techniques. Low rectal lesions (close to the anus) can be removed through the anus if localized, and cancers higher up can usually be removed through an abdominal incision, re-connecting the colon down very low, close to the anus. The American Cancer Society has set a goal of reducing the incidence of colon cancer by 50% by the year 2015. In order to reach this goal, the routine use of colonoscopy or flexible sigmoidoscopy screening must be fully implemented. Current recommendations are for screening colonoscopy in all patients beginning at age 50, and every 10 years thereafter. For African American patients and in patients with a family history of colon cancer, screening should begin at age 45. Our web site provides more information about colon polyps and cancer under the patient information link. |
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In 2002, the surgeons at DeKalb Surgical Associates performed 169 laparoscopic cholecystectomies. Indications for surgery included: chronic cholecystitis and other chronic conditions in 59%, acute cholecystitis in 28%, and biliary pancreatitis in 13%. The median length of stay was < 1 day. For patients with acute cholecystitis the average length of stay was 3.8 days. Although return to work was not analyzed, most patients return to their usual activities in 5-10 days after an elective procedure.
There were only 2 cases in which the conversion to an open cholecystectomy was necessary, and in both cases this was for severe acute cholecystitis. This represents a conversion percentage of only 1.2%, which compares extremely well with published reports, most of which are in the 5-10% range. There were no cases of common bile duct injury. Intra-operative cholangiography was performed in 30%, on a selective basis. Four percent of patients had common bile duct stones, which were treated either with laparoscopic common bile duct exploration, or with post-operative ERCP.
Not all
patients who are referred with gallstones undergo surgery. Patients with
atypical symptoms undergo further evaluation looking for other pathology,
such as peptic ulcer disease, esophageal reflux, or irritable bowel
syndrome. In patients whose symptoms are correlated with other pathology,
surgery is not recommended unless more typical symptoms develop.
We reviewed all of the breast biopsies performed on our patients for the year 2002. All in all, 445 biopsies were performed, including FNA’s, core biopsies, stereotactic biopsies, and excisional biopsies. There were 82 patients diagnosed with breast cancer, including 11 (13%) with non-invasive disease. One patient had bilateral cancer. The diagnosis was made by needle biopsy in 73 (88%), usually at the first office visit, utilizing ultrasound for localization as needed, thereby allowing for a rapid diagnosis, and subsequent definitive surgical treatment with a single operative procedure.
There were 69 stereotactic biopsies performed, for microcalcifications in 49, and for a nodular or asymmetric density in 20. Cancer was identified in 16 (23%). In 9 of these 16 patients (56%), the cancer was non-invasive.
Of the 82 patients with breast cancer, 7 refused treatment or went elsewhere. Of the remaining 75 patients, 66 (88%) underwent breast-conserving surgery. Compared to published data, this is a remarkably high percentage. In many reported series, particularly in the southeastern United States, conservative surgery rates are typically only about 50%. Sentinel node biopsy was routinely used in all of these patients for clinically node negative disease. Mastectomy was recommended in the other 9 patients because of either a large tumor size, more than one cancer in the breast, strong family history, or involved margins on attempted breast-conserving surgery.
The average tumor size, including those with DCIS
(non-invasive cancer),
was 1.8 cm, with a median size of 1.3 cm. Thirty-seven percent of
patients had tumors less than or equal to 1 cm in size.
In summary, prompt and
accurate evaluation of breast problems constitutes a major focus for
DeKalb Surgical Associates. We are committed to providing a timely and
cost-effective diagnosis, with a high priority for
breast conservation and sentinel node biopsy for patients diagnosed with
cancer.
Customized Circular Cutting Device Lowers Re-excision Rate for Breast Cancer (updated June 2008)
Women with breast cancer can be overwhelmed with anxiety from the very moment they learn of their diagnosis. Fortunately for most women at DeKalb Surgical, the diagnosis is made early, with a correspondingly good prognosis. We then give extra effort to achieve a maximum cure with a minimum of surgery.
Particular emphasis must be given to obtaining clear margins around the lump of cancer. This is essential in assuring a low risk of local recurrence in the breast. If the margins are not clear, the patient must undergo either a re-excision, or a mastectomy. For most surgeons, anywhere from 20% to over 50% of their patients must have a second procedure to obtain clear margins. Mastectomy rates may run as high as 60%.
We have focused on this issue at DeKalb Surgical Associates over the past 3 years. As a result, our re-excision rate for breast cancer patients undergoing breast conserving surgery is only 14%. The primary method for achieving these superior results if the use of a customized circular surgical cutting device (designed and patent pending by Dr. Kennedy) that standardizes the specimen removal, allowing for more precise assessment of the surgical margins. As a corollary, our mastectomy rate is also remarkably low, at only 5%, excluding patients who present with advanced disease. Use of this instrument also meshes nicely with a new technique for radiation therapy, using a MammoSite balloon. Our experience with this method of partial breast irradiation has been extremely favorable. Here is a link to more information.
By minimizing the need for additional surgery, our patients complete their treatment more quickly. This helps to reduce the anxiety that comes with the diagnosis, allowing them to resume their daily routine.
Hernia Repair- Recurrence Rate
(updated July 2007)
DeKalb Surgical Associates routinely follows up patients who have previously undergone inguinal hernia repairs to monitor for recurrence. Below are summaries of these questionnaire results, with the most recent summary listed first. If you just want the final result, our cumulative recurrence risk for all hernia repairs is 1.1% based on all repairs done, and 2.5%, based on only those patients who responded to the questionnaire.
In July 2007, we once again sent out a questionnaire to our hernia patients from 2 years ago. Of the entire group, there were 6 confirmed hernias out of 291 repairs (2.06%). Of those who responded, the confirmed hernia recurrence rate is 4.11% (6/146).
Compared to the previous follow-ups conducted in November 2001, July 2003, and 2006, response rate was similar, at 53%. If the results of the four surveys are combined, there are 11 confirmed recurrences out of a total of 763 repairs, for a rate of 1.44%, and a rate of 2.54% (11/433) for only those who responded. Three of the eleven confirmed recurrences were done laparoscopically.
If only the non-laparoscopic repairs are considered, the recurrence rate for the four combined surveys is 1.11% (8/722), and 2.10% (8/381) of only those who responded. If only the laparoscopic repairs are considered, the corresponding recurrence rates for the three combined surveys are 7.32% (3/41) and 11.5% (3/26).
We have previously identified a higher recurrence rate among patients undergoing a laparoscopic repair, and the updated data also reflects that finding. Both repair methods are offered to our patients, "traditional" or laparoscopic, although the majority of patients undergo an open repair. Most often, this is done as an outpatient, under local anesthesia with sedation. The laparoscopic repair is also done as an outpatient, but under general anesthesia. In most cases, the repair is reinforced with mesh, which helps decrease the recurrence risk, as well as the amount of pain experience after surgery. Time out of work is variable, depending on the type of work done, employer expectations, and your own individual response to the surgery. For non-strenuous (desk-type) jobs, many patients will be back at work within three to seven days. For very heavy labor (construction-type), the time off work may be up to four weeks or more.
2006 results
In early 2006, we once again sent out a questionnaire to our hernia patients from 2 years ago. Of the entire group, there was 1 confirmed hernia out of 176 repairs (0.57%). Of those who responded, the confirmed hernia recurrence rate is 1.01% (1/99).
Compared to the previous follow-ups conducted in November 2001, and fall of 2003, response rate was similar, though slightly lower. The percentage of patients responding was 53%. The response rate for the last two surveys was 59% and 63%, respectively. This survey was conducted several months later for the entire group as an average, compared to previous surveys, and this is the probable explanation for the lower response rate.
If the results of the three surveys are combined, there are 5 confirmed recurrences out of a total of 494 repairs, for a rate of 1.01%, and a rate of 1.74% (5/187) for only those who responded. Two of the five confirmed recurrences were done laparoscopically.
If only the non-laparoscopic repairs are considered, the recurrence rate for the three combined surveys is 0.68% (3/443), and 1.23% (3/243) of only those who responded. If only the laparoscopic repairs are considered, the corresponding recurrence rates for the three combined surveys are 6.9% (2/29) and 11.1% (2/18).
2003 results
Patients who had hernia repairs between 18 and 36 months ago were contacted by mail or telephone in the fall of 2003. Followup rate was 59%.
There were 159 patients with a total of 180 hernia repairs (21 with bilateral repairs) performed between October 1, 2000, and March 31, 2002. There were 3 recurrences identified for a recurrence rate of 1.7%. This recurrence rate compares very favorably with published recurrence rates. If results are combined with our previous 2 year survey, the overall recurrence rate is 4/318, or 1.3%.