Immediate breast reconstruction with prostheses after conservative treatment plus intraoperative radiotherapy. long term esthetic and oncological outcomes

Electron intraoperative radiotherapy (ELIOT) has been introduced for breast conservative treatment (BCT) with promising oncological outcome. Thus, immediate breast reconstruction with prosthesis after BCT became possible due to minimal radiation effect on local tissue from ELIOT. We reported oncological and esthetical results of 29 BCT patients who had immediate implant reconstruction plus 21 Gy-ELIOT as the sole radiation treatment. All patients had prosthesis in ipsilateral breast and had simultaneous contralateral augmentation for symmetrical procedure. The average age was 52.3 years. There were stage Ia thirteen cases, stage Ib seven cases, stage IIa six cases and stage IIIb one case and two cases of intraepithelial neoplasia. From 54.2 (36-88) months follow up, the capsular contracture grading in the reconstructed breast from ELIOT-side is comparable with non-irradiated contralateral side. There was one patient who developed local recurrence (LR) and later on dead with breast related event (LR=0.76% per year). There was no primary ipsilateral carcinomas and distant metastasis.     

Inguinal hernia repair: Toward Asian guidelines

Groin hernias are very common, and surgical treatment is usually recommended. In fact, hernia repair is the most common surgical procedure performed worldwide. In countries such as the USA, China, and India, there may easily be over 1 million repairs every year. The need for this surgery has become an important socioeconomic problem and may affect health‐care providers, especially in aging societies. Surgical repair using mesh is recommended and widely employed in Western countries, but in many developing countries, tissue‐to‐tissue repair is still the preferred surgical procedure due to economic constraints. For these reason, the development and implementation of guidelines, consensus, or recommendations may aim to clarify issues related to best practices in inguinal hernia repair in Asia. A group of Asian experts in hernia repair gathered together to debate inguinal hernia treatments in Asia in an attempt to reach some consensus or develop recommendations on best practices in the region. The need for recommendations or guidelines was unanimously confirmed to help overcome the discrepancy in clinical practice between countries; the experts decided to focus mainly on the technical aspects of open repair, which is the most common surgery for hernia in our region. After the identification of 12 main topics for discussion (indication, age, and sex; symptomatic and asymptomatic hernia: type of hernia; type of treatment; hospital admission; preoperative care; anesthesia; surgical technique; perioperative care; postoperative care; early complications; and long‐term complications), a search of the literature was carried out according to the five levels of the Oxford Classification of Evidence and the four grades of recommendation.     

The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery

Background

The aim of the present study was to evaluate the effects of preoperative nutritional status on the short-term outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery.

Methods

This prospective observational study included 149 patients who underwent elective resection of colorectal cancer with ERAS from January 2011 to January 2014 in a university hospital. Subjective global assessment (SGA) was used to determine preoperative nutritional status. Primary outcomes included the length of postoperative stay, postoperative morbidity, gastrointestinal recovery, and 30-day readmission.

Results

The patients were divided into 3 groups according to the SGA classification. There were 96 patients (64.4 %) in SGA-A (well-nourished), 48 (32.2 %) in SGA-B (mild to moderately malnourished), and 5 (3.4 %) in SGA-C (severely malnourished). Patients in SGA-A had the median length of postoperative stay of 4 days (range 2–23), which was significantly shorter compared to SGA-B (5 days; range 2–16; p < 0.01) and SGA-C (7 days; range 4–17; p < 0.01). The overall complication rates of SGA-A, SGA-B, and SGA-C patients were 11, 31 % (adjusted OR 3.76; 95 % CI 1.36–10.36; p < 0.01) and 40 % (adjusted OR 2.15; 95 % CI 0.07–63.64; p = 0.66). Mean time to resumption of normal diet and time to first defecation were 1.6 ± 1.3 and 2.2 ± 0.9 days in SGA-A, 2.6 ± 1.7 and 3.1 ± 1.6 days in SGA-B (p < 0.01 compared to SGA-A) and 3.2 ± 2.4 days and 2.6 ± 1.5 days in SGA-C (p = 0.07 and p = 0.1 compared to SGA-A, respectively). No 30-day mortality occurred in any group. One patient in SGA-A (1 %), and 3 patients in SGA-B (6 %) had unplanned 30-day re-admission; p = 0.11.

Conclusions

Within an ERAS programme for colorectal cancer surgery, malnourished patients were at risk for increased postoperative morbidity, delayed recovery of gastrointestinal function, and prolonged length of hospital stay.     

Persistent Perineal Sinus After Ileoanal Pouch Excision in Inflammatory Bowel Diseases: Incidence,Risk Factors,and Clinical Course

Purpose  This study was designed to determine the incidence of persistent perineal sinus after pouch excision in inflammatory bowel disease, risk factors, and long-term clinical course. Methods  The study included 35 consecutive patients who underwent pouch excision at St. Mark’s Hospital, London, between 1996 and 2006. Incidence of persistent perineal sinus and its long-term clinical course were reported. Sixteen variables were analyzed to determine their association with persistent perineal sinus. Results  There were 17 men and 18 women with median age of 37 (range, 20–57) years. The final diagnosis was ulcerative colitis in 28 and Crohn’s disease in 7 patients. The indications for pouch excision included pelvic or perineal sepsis in 60 percent, pouchitis in 23 percent, and poor pouch function in 17 percent. Persistent perineal sinus was diagnosed in 14 patients (40 percent). Pouch excision for fistula or abscess in the pelvis or perineum (odds ratio, 8; 95 percent confidence interval, 1.4–45.5) was an independent predictor for persistent perineal sinus. Twenty-six procedures were performed in patients with persistent perineal sinus and resulted in healing in 64 percent. Curettage was the most common procedure used. Conclusions  Pouch excision for pelvic or perineal sepsis was an independent predictor for persistent perineal sinus. Poster presentation at the meeting of the Association of Coloproctology of Great Britain and Ireland, Birmingham, United Kingdom, June 30 to July 3, 2008. Reprints are not available.     

Pharmacological characteristics of endothelin receptors on sheep rectal blood vessels

Haemorrhoids is associated with high blood flow of the anorectal region. The question of whether pharmacological manipulation of vascular supply can relieve the symptoms of haemorrhoids has been raised. In order to undertake this type of clinical investigation, it is first essential to gain a better understanding of the properties of vascular receptors that may regulate blood flow into anal cushions and haemorrhoids. Due to the limited availability of human anorectal specimens and the good reliability of sheep tissue as an experimental model of human anorectal diseases, we studied the properties of endothelin receptors in sheep rectal artery (SRA) and vein (SRV), the vessels contributing to the blood flow of haemorrhoidal plexus, using isometric tension recordings. We found that endothelin-1 and sarafotoxin 6a were very potent constrictor agents in both SRA and SRV. The selective ET_A receptor antagonist PD156707 (100 nM) produced a parallel rightward displacement of ET-1-induced contractions in both vessels and abolished sarafotoxin 6a-induced contractions in the SRA. PD156707 (3 μM) practically abolished contractions to ET-1 in the SRA, suggesting that the response is entirely mediated by ET_A receptors. While, the selective ET_B receptor antagonist BQ788 (100 nM) caused no significant change in ET-1-induced contractions in both vessels, a minor role for ET_B receptor subtype to responses to sarafotoxin 6a in the artery was suggested.     

Locoregional recurrence in patients with HER2 positive breast cancer

Literature shows that HER2/neu positive breast cancer cells are more sensitive to radiation-induced apoptosis by targeting the epidermal growth factor receptor family tyrosine kinase. We selected 466 patients with pT1-2 HER2/neu positive tumors who received adjuvant trastuzumab for primary invasive breast cancer. Patients were divided into three groups [Quadrantectomy followed by conventional radiotherapy vs Quadrantectomy followed by Intra-operative radiotherapy with electrons vs Mastectomy without radiotherapy]. After a median follow-up of 52 months, the 5-year cumulative incidence of locoregional recurrence (LRR) was 1.9%, 11.5% and 5.0% respectively (p < 0.01). At the multivariate analysis, extensive perivascular invasion, Luminal B HER2/Progesterone Receptor (PgR) negative status and Quadrantectomy followed by Intra-operative radiotherapy with electrons have significantly increased the risk of LRR. Our results suggest that HER2/neu positive breast cancer might have better outcomes when treated simultaneously with external radiotherapy and trastuzumab. Moreover, we underline the importance of PgR and further new stratification of risk among luminal subtypes.     

The white adipose tissue used in lipotransfer procedures is a rich reservoir of CD34+ progenitors able to promote cancer progression

Previous studies have suggested a "catalytic role" in neoplastic angiogenesis and cancer progression for bone marrow-derived endothelial progenitor cells (EPC). However, preclinical and clinical studies have shown that the quantitative role of marrow-derived EPCs in cancer vascularization is extremely variable. We have found that human and murine white adipose tissue (WAT) is a very rich reservoir of CD45-CD34(+) EPCs with endothelial differentiation potential, containing a mean of 263 times more CD45-CD34(+) cells/mL than bone marrow. Compared with marrow-derived CD34(+) cells mobilized in blood by granulocyte colony-stimulating factor, purified WAT-CD34(+) cells expressed similar levels of stemness-related genes, significantly increased levels of angiogenesis-related genes, and increased levels of FAP-α, a crucial suppressor of antitumor immunity. In vitro, WAT-CD34(+) cells generated mature endothelial cells and capillary tubes as efficiently as mature mesenchymal cells. The coinjection of human WAT-CD34(+) cells from lipotransfer procedures contributed to tumor vascularization and significantly increased tumor growth and metastases in several orthotopic models of human breast cancer in immunodeficient mice. Endothelial cells derived from human WAT-CD34(+) cells lined the lumen of cancer vessels. These data indicate that CD34(+) WAT cells can promote cancer progression and metastases. Our results highlight the importance of gaining a better understanding of the role of different WAT-derived cells used in lipotransfer for breast reconstruction in patients with breast cancer.     

The effect of pre-operative topical anaesthetic cream on the ablative width and coagulative depth of ablative fractional resurfacing laser

Topical anaesthetic cream (TAC) is commonly used as a pre-treatment of ablative fractional resurfacing (AFR) laser. Most of anaesthetic cream contains distilled water as major component. Therefore, pre-operative TAC may interfere the photothermal reaction in the skin treated with fractional carbon-dioxide (FCO₂) laser and fractional erbium-doped yttrium aluminium garnet (FEr:YAG) laser. The objective of the study was to compare the ablative width (AW) and coagulative depth (CD) of AFR laser with and without pre-treatment with TAC. Four Thai females who underwent abdominoplasty were included in the study. The excised skin of each subject was divided into four areas. TAC (eutectic mixture of local anaesthesia; EMLA) with 1-h occlusion was applied only on the first and second areas. The first and third areas were treated with FCO₂ at 15 mj and 5% density. The second and fourth areas were treated with FEr:YAG at 28 J/cm² and 5% density. Six biopsied specimens were obtained from each area. A total of 96 specimens (24 specimens from each area) were collected from four patients and examined randomly by two dermatopathologists. The ablative width and coagulative depth from each specimen were determined. In FCO₂-treated specimens, the mean AW of the specimens that were pre-treated with TAC and control was 174.86?±?24.57 and 188.52?±?41.32 μm. The mean CD of the specimens that were pre-treated with TAC and control was 594.96?±?111.72 and 520.03?±?147.40 μm. There were no significant differences in AW and CD between both groups (p?=?0.53 and p?=?0.15). In FEr:YAG-treated specimens, the mean AW of the specimens that were pre-treated with TAC and control was 381.11?±?48.02 and 423.65?±?60.16 μm. The mean CD of the specimens that were pre-treated with TAC and control was 86.03?±?29.44 and 71.59?±?18.99 μm. There were no significant differences in AW and CD between both groups (p?=?0.16 and p?=?0.24). The pre-treatment with TAC provided no statistically difference from the control group on AW and CD of both FCO₂ and FEr:YAG laser irradiation. However, there was a tendency to have narrower AW and deeper CD of the areas that were pre-treated with TAC when comparing to that of the control.