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November 2016 Featured Articles, Volume 223
CONTINUING MEDICAL EDUCATION PROGRAM
November 2016 Featured Articles, Volume 223
Get credit right away by taking all CME tests online http://jacscme.facs.org Article 1: Breast, General Surgery
Radial scar at percutaneous breast biopsy that does not require surgery. Leong RY, Kohli MK, Zeizafoun N, et al. J Am Coll Surg 2016;223:712e716 Article 2: General Surgery
Management of uncomplicated acute appendicitis as day case surgery: feasibility and a critical analysis of exclusion criteria and treatment failure. Grelpois G, Sabbagh C, Cosse C, et al. J Am Coll Surg 2016;223:694e703 Article 3: Infections; General Surgery
Impact of hair removal on surgical site infection rates: a prospective randomized noninferiority trial. Kowalski TJ, Kothari SN, Mathiason MA, Borgert AJ. J Am Coll Surg 2016;223:704e711
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME and Self-Assessment credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two articles are available each month in the print version, and usually 4 are available online for each monthly issue, going back 24 months.
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Radial scar at percutaneous breast biopsy that does not require surgery Leong RY, Kohli MK, Zeizafoun N, et al J Am Coll Surg 2016;223:712e716 Learning Objectives: After studying this article, surgeons should understand the difference between mammographic and pathologic radial scar of the breast and their corresponding likelihoods of finding malignancy at surgical excision. Question 1 Concerning radial scars on mammography compared with radial scars at percutaneous breast core biopsy:
Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
a. Mammographic radial scars have lower likelihood of malignancy at surgical excision. b. Pathologic radial scars are most frequently found at percutaneous breast biopsy for masses on ultrasound. c. Pathologic radial scars are frequently found at surgical excision of mammographic radial scars. d. The majority of pathologic radial scars are associated with a proliferative breast lesion. e. Mammographic radial scars do not require biopsy.
Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Critique: Mammographic radial scars have a higher likelihood of associated malignancy than pathologic radial scars. For this reason mammographic radial scars require biopsy, although the majority of mammographic ª 2016 Published by Elsevier Inc. on behalf of the American College of Surgeons.
739
http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.567 ISSN 1072-7515/16
740
J Am Coll Surg
Continuing Medical Education Program
radial scars are in fact due to pathologic radial scars. Pathologic radial scars are most frequently found at percutaneous core biopsy for calcifications on mammography and in this study, 25% were associated with a proliferative breast lesion.
b. Residual calcifications on mammography after stereotactic needle biopsy c. Any patient can be followed without surgical excision d. Lobular neoplasia with the radial scar e. Absence of any associated proliferative lesion
Question 2 In this study the pathologic finding at percutaneous needle biopsy most frequently associated with malignancy was:
Critique: This study had too few patients (n ¼ 17) with papilloma associated with the radial scar at needle biopsy to safely conclude that these patients can be followed. The same can be said about the 16 patients with lobular neoplasia and, in addition, 1 of these patients was found to have invasive lobular carcinoma at surgical excision, indicating that these patients should probably not be followed. Residual calcifications after a stereotactic breast needle biopsy may indicate inadequate sampling. Because malignancy was found at surgical excision in 5 of the 21 patients with atypical ductal hyperplasia associated with radial scar, these patients cannot be followed without surgical excision. Surgical excision is unnecessary when radial scar is found at percutaneous needle biopsy without an associated proliferative lesion. Surgical excision is still indicated when radial scar is associated with atypical ductal hyperplasia or lobular neoplasia.
a. b. c. d. e.
Papilloma Atypical ductal hyperplasia Papilloma with atypical ductal hyperplasia Sclerosing adenosis Atypical lobular hyperplasia
Critique: Surgical upgrades to malignancy in this study were found with atypical ductal hyperplasia and lobular neoplasia. Of the 21 cases with atypical ductal hyperplasia, 4 were found to have ductal carcinoma in situ at surgical excision and 1 had invasive ductal cancer; 1 invasive lobular carcinoma was found in the 16 patients with lobular neoplasia. No cancers were found at surgical excision for papilloma. Sclerosing adenosis at percutaneous breast biopsy is not associated with increased likelihood of malignancy at surgical excision. Question 3 In this study, the majority of radial scars found at percutaneous needle biopsy of the breast were for: a. b. c. d. e.
Architectural distortion on mammography Enhancement on breast MRI Masses on ultrasound Calcifications on mammography Masses with calcifications on mammography
Critique: In this study of pathologic radial scars at percutaneous breast needle biopsy, 9% of the biopsies were for enhancement on MRI and 4% were for mammographic asymmetry or architectural distortion. Almost one-third of the percutaneous biopsies were ultrasound-guided biopsies for masses; the majority were stereotactic biopsies for mammographic calcifications. Question 4 Which of the following patient scenarios is most appropriate to follow without surgical excision after finding radial scar at percutaneous needle biopsy of the breast: a. Papilloma associated with the radial scar
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Management of uncomplicated acute appendicitis as day case surgery: feasibility and a critical analysis of exclusion criteria and treatment failure Grelpois G, Sabbagh C, Cosse C, et al J Am Coll Surg 2016;223:694e703 Learning Objectives: The reader should learn to evaluate the feasibility of day case (same-day) surgery for uncomplicated acute appendicitis. Question 1 In the overall, intent-to-treat population of patients with acute appendicitis, the rate of success of day case surgery is: a. b. c. d. e.
5% 11% 31% 61% 80%
Critique: In this study, we found that almost one-third of patients with acute appendicitis were
Vol. 223, No. 5, November 2016
discharged after successful day case surgery. The proportion of patients with successful day case surgery was 31.5% (76 of 240) in the intent-to-treat population and 91.5% (76 of 83) in the per-protocol population, which was the population not meeting any of the pre- or perioperative exclusion criteria. Question 2 One of the predictive factors of success of day case surgery is: a. b. c. d. e.
BMI < 28 kg/m2 No anticoagulation No inflammatory bowel disease Age < 50 years Coprolith (fecalith)
Critique: The St Antoine score is a predictive score for successful day case surgery. The 5 factors included in this score are: BMI < 28 kg/m2; preoperative Creactive protein level < 30 mg/dL; preoperative leukocyte count < 15,000 /mm3; diameter of the appendix 10 mm; and no radiologic signs of perforation. Question 3 The satisfaction of patients for day case surgery is: a. 10% b. 30%
Continuing Medical Education Program
741
c. 50% d. 70% e. 99% Critique: The satisfaction of the patients was very high and is another factor that validates day case surgery for uncomplicated acute appendicitis. In the per-protocol population, 99% of the patients (n ¼ 82) were satisfied with day case surgery. The only unsatisfied patient had not wanted to wait for the surgeon before being discharged. The Short Form 36 demonstrated good quality of life.
Question 4 Compared with unplanned admissions in hernia repair, the rate of unplanned admission for noncomplicated acute appendicitis is: a. b. c. d. e.
Similar Higher Lower Twice as high Twice as low
Critique: The rate of unplanned admission for acute appendicitis is similar to that of other procedures such as hernia repair or sleeve gastrectomy.
742
Continuing Medical Education Program
J Am Coll Surg
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue). Issues are available for the past 24 months. You can print your certificate immediately.
For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
November 2016 Featured Articles, Volume 223 Radial scar at percutaneous breast biopsy that does not require surgery Leong RY, Kohli MK, Zeizafoun N, et al. J Am Coll Surg 2016;223:712e716 Management of uncomplicated acute appendicitis as day case surgery: feasibility and a critical analysis of exclusion criteria and treatment failure Grelpois G, Sabbagh C, Cosse C, et al. J Am Coll Surg 2016;223:694e703
November 2016 Featured Articles, Volume 223
Get credit right away by taking all CME tests online http://jacscme.facs.org Article 1: Breast, General Surgery
Radial scar at percutaneous breast biopsy that does not require surgery. Leong RY, Kohli MK, Zeizafoun N, et al. J Am Coll Surg 2016;223:712e716 Article 2: General Surgery
Management of uncomplicated acute appendicitis as day case surgery: feasibility and a critical analysis of exclusion criteria and treatment failure. Grelpois G, Sabbagh C, Cosse C, et al. J Am Coll Surg 2016;223:694e703 Article 3: Infections; General Surgery
Impact of hair removal on surgical site infection rates: a prospective randomized noninferiority trial. Kowalski TJ, Kothari SN, Mathiason MA, Borgert AJ. J Am Coll Surg 2016;223:704e711
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME and Self-Assessment credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two articles are available each month in the print version, and usually 4 are available online for each monthly issue, going back 24 months.
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Radial scar at percutaneous breast biopsy that does not require surgery Leong RY, Kohli MK, Zeizafoun N, et al J Am Coll Surg 2016;223:712e716 Learning Objectives: After studying this article, surgeons should understand the difference between mammographic and pathologic radial scar of the breast and their corresponding likelihoods of finding malignancy at surgical excision. Question 1 Concerning radial scars on mammography compared with radial scars at percutaneous breast core biopsy:
Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
a. Mammographic radial scars have lower likelihood of malignancy at surgical excision. b. Pathologic radial scars are most frequently found at percutaneous breast biopsy for masses on ultrasound. c. Pathologic radial scars are frequently found at surgical excision of mammographic radial scars. d. The majority of pathologic radial scars are associated with a proliferative breast lesion. e. Mammographic radial scars do not require biopsy.
Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Critique: Mammographic radial scars have a higher likelihood of associated malignancy than pathologic radial scars. For this reason mammographic radial scars require biopsy, although the majority of mammographic ª 2016 Published by Elsevier Inc. on behalf of the American College of Surgeons.
739
http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.567 ISSN 1072-7515/16
740
J Am Coll Surg
Continuing Medical Education Program
radial scars are in fact due to pathologic radial scars. Pathologic radial scars are most frequently found at percutaneous core biopsy for calcifications on mammography and in this study, 25% were associated with a proliferative breast lesion.
b. Residual calcifications on mammography after stereotactic needle biopsy c. Any patient can be followed without surgical excision d. Lobular neoplasia with the radial scar e. Absence of any associated proliferative lesion
Question 2 In this study the pathologic finding at percutaneous needle biopsy most frequently associated with malignancy was:
Critique: This study had too few patients (n ¼ 17) with papilloma associated with the radial scar at needle biopsy to safely conclude that these patients can be followed. The same can be said about the 16 patients with lobular neoplasia and, in addition, 1 of these patients was found to have invasive lobular carcinoma at surgical excision, indicating that these patients should probably not be followed. Residual calcifications after a stereotactic breast needle biopsy may indicate inadequate sampling. Because malignancy was found at surgical excision in 5 of the 21 patients with atypical ductal hyperplasia associated with radial scar, these patients cannot be followed without surgical excision. Surgical excision is unnecessary when radial scar is found at percutaneous needle biopsy without an associated proliferative lesion. Surgical excision is still indicated when radial scar is associated with atypical ductal hyperplasia or lobular neoplasia.
a. b. c. d. e.
Papilloma Atypical ductal hyperplasia Papilloma with atypical ductal hyperplasia Sclerosing adenosis Atypical lobular hyperplasia
Critique: Surgical upgrades to malignancy in this study were found with atypical ductal hyperplasia and lobular neoplasia. Of the 21 cases with atypical ductal hyperplasia, 4 were found to have ductal carcinoma in situ at surgical excision and 1 had invasive ductal cancer; 1 invasive lobular carcinoma was found in the 16 patients with lobular neoplasia. No cancers were found at surgical excision for papilloma. Sclerosing adenosis at percutaneous breast biopsy is not associated with increased likelihood of malignancy at surgical excision. Question 3 In this study, the majority of radial scars found at percutaneous needle biopsy of the breast were for: a. b. c. d. e.
Architectural distortion on mammography Enhancement on breast MRI Masses on ultrasound Calcifications on mammography Masses with calcifications on mammography
Critique: In this study of pathologic radial scars at percutaneous breast needle biopsy, 9% of the biopsies were for enhancement on MRI and 4% were for mammographic asymmetry or architectural distortion. Almost one-third of the percutaneous biopsies were ultrasound-guided biopsies for masses; the majority were stereotactic biopsies for mammographic calcifications. Question 4 Which of the following patient scenarios is most appropriate to follow without surgical excision after finding radial scar at percutaneous needle biopsy of the breast: a. Papilloma associated with the radial scar
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Management of uncomplicated acute appendicitis as day case surgery: feasibility and a critical analysis of exclusion criteria and treatment failure Grelpois G, Sabbagh C, Cosse C, et al J Am Coll Surg 2016;223:694e703 Learning Objectives: The reader should learn to evaluate the feasibility of day case (same-day) surgery for uncomplicated acute appendicitis. Question 1 In the overall, intent-to-treat population of patients with acute appendicitis, the rate of success of day case surgery is: a. b. c. d. e.
5% 11% 31% 61% 80%
Critique: In this study, we found that almost one-third of patients with acute appendicitis were
Vol. 223, No. 5, November 2016
discharged after successful day case surgery. The proportion of patients with successful day case surgery was 31.5% (76 of 240) in the intent-to-treat population and 91.5% (76 of 83) in the per-protocol population, which was the population not meeting any of the pre- or perioperative exclusion criteria. Question 2 One of the predictive factors of success of day case surgery is: a. b. c. d. e.
BMI < 28 kg/m2 No anticoagulation No inflammatory bowel disease Age < 50 years Coprolith (fecalith)
Critique: The St Antoine score is a predictive score for successful day case surgery. The 5 factors included in this score are: BMI < 28 kg/m2; preoperative Creactive protein level < 30 mg/dL; preoperative leukocyte count < 15,000 /mm3; diameter of the appendix 10 mm; and no radiologic signs of perforation. Question 3 The satisfaction of patients for day case surgery is: a. 10% b. 30%
Continuing Medical Education Program
741
c. 50% d. 70% e. 99% Critique: The satisfaction of the patients was very high and is another factor that validates day case surgery for uncomplicated acute appendicitis. In the per-protocol population, 99% of the patients (n ¼ 82) were satisfied with day case surgery. The only unsatisfied patient had not wanted to wait for the surgeon before being discharged. The Short Form 36 demonstrated good quality of life.
Question 4 Compared with unplanned admissions in hernia repair, the rate of unplanned admission for noncomplicated acute appendicitis is: a. b. c. d. e.
Similar Higher Lower Twice as high Twice as low
Critique: The rate of unplanned admission for acute appendicitis is similar to that of other procedures such as hernia repair or sleeve gastrectomy.
742
Continuing Medical Education Program
J Am Coll Surg
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue). Issues are available for the past 24 months. You can print your certificate immediately.
For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
November 2016 Featured Articles, Volume 223 Radial scar at percutaneous breast biopsy that does not require surgery Leong RY, Kohli MK, Zeizafoun N, et al. J Am Coll Surg 2016;223:712e716 Management of uncomplicated acute appendicitis as day case surgery: feasibility and a critical analysis of exclusion criteria and treatment failure Grelpois G, Sabbagh C, Cosse C, et al. J Am Coll Surg 2016;223:694e703