This Month in Archives of Surgery FREE

Although only a small segment of patients with breast cancer were evaluated, 22% of those treated (7 of 32) had a deleterious mutation and opted for bilateral mastectomy. Thus, genetic cancer risk assessment at the time of breast cancer diagnosis had a significant effect on women's treatment decisions. The invited critique rightly points out the small series and the lack of follow-up of these patients compared with a group who elected conservative breast treatment.

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Solitary papillomas were associated with breast cancer in 10.3% of 95 specimens examined. An additional 8.8% had carcinomas within the papilloma. The risk of associated malignancy was not significantly different between solitary and multiple ductal papilloma.

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Analyzing the needs of more than 300 patients categorized as those treated medically or those who underwent surgical fundoplication, it was found that in 4 follow-up years, the number of physician visits and amount of medication was less each year in the surgical group. This provides further evidence of the effectiveness of fundoplication vs medical therapy.

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Three important clinical problems are discussed this month. The first relates to pancreatic resection for adenocarcinoma. In the last 2 decades, we have witnessed tremendous improvement in mortality rates. No longer is pancreatic fistula a controlling problem. However, the overall outlook for these patients has changed little. Studying adjuvant therapy for this disease is critical, and this point is emphasized by Büchler and colleagues. They also note that delayed gastric emptying continues to be a problem worthy of study.

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The second concerns the judgment of creating a defunctioning stoma to protect colorectal anastomoses in patients undergoing low anterior resection for rectal cancer. Koperna deals with its cost-effectiveness. Heald, champion of total mesenteric excision for rectal cancer, points out in his invited critique that patients care little about initial costs. They want the lowest possible long-term outcome costs: zero for a cure with no stoma. Koperna asserts that a leak rate must be higher than 15% to financially justify the addition of a temporary stoma. Common sense must prevail.

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The third involves the appropriate treatment for esophageal cancer and who should be operating on these patients. The treatment of esophageal cancer remains difficult, with multiple options including extended esophagectomy with radical lymph node dissection. No statistical difference has been established regarding survival in prospective randomized clinical trials; 3-field dissection has a much higher morbidity rate. In other thoracic malignancies, meticulous staging and well-thought-out multicenter clinical trials helped develop treatment patterns of neoadjuvant chemoradiation treatment and surgery. The same technique must provide answers for this disease.

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