乳腺癌保留乳房术后影响乳房形态的多因素分析

目的探讨乳腺癌保乳术后影响乳房形态的因素及提高保乳术后乳房美学效果的方法。方法由整形外科医师和患者分别对67例乳腺癌保乳术后的美学效果做出各自独立的评价，单因素分析采用Mann-Whitney U检验，而多因素分析则应用Logistic回归的方法。结果医师对保乳术后乳房形态的满意率为65．7％。单元素分析中，年龄（P=0．003）、体重指数（P=0．002）、绝经状况（P=0．002）、放疗剂量（P=0．022）、肿物位于外上象限时的切口数量（P=0．036）、切除次数（P=0．036）、纤维化（P=0．002）、手术方式（P=0．002）对保乳术后乳房形态具有明显的影响。多元素分析中，纤维化、手术方式、放疗剂量对术后乳房形态具有明显影响（P=0．009、0．001、0．019）。患者对保乳术后乳房形态的满意率为76．1％。单元素分析中，手术方式（P=0．001）和纤维化（P=0．045）对乳房形态影响明显，差异具有统计学意义。多元素分析中，手术方式对术后乳房形态影响明显（P=0．005）。结论患者和医师的满意率具有正相关性（R=0．701，P〈O．01）。在可能影响乳房美学的27项因素中，年龄、体重指数、绝经状况、放疗剂量、肿物位于外上象限时的切口数量、切除次数、纤维化、手术方式对术后乳房形态影响明显。     

Factors determining esthetic outcome after breast cancer conservative treatment

The aim of this study was to evaluate the factors that determine esthetic outcome after breast cancer conservative treatment, based on a consensual classification obtained with an international consensus panel. Photographs were taken from 120 women submitted to conservative unilateral breast cancer surgery (with or without axillary surgery) and radiotherapy. The images were sent to a panel of observers from 13 different countries and consensus on the classification of esthetic result (recorded as excellent, good, fair or poor) was obtained in 113 cases by means of a Delphi method. For each patient, data were collected retrospectively regarding patient characteristics, tumor, and treatment factors. Univariate and multivariate analysis were used to evaluate the correlation between these factors and overall cosmetic results. On univariate analysis, younger and thinner patients as well as patients with lower body mass index (BMI) and premenopausal status obtained better cosmetic results. In the group of tumor- and treatment-related factors, larger removed specimens, clearly visible scars, the use of chemotherapy and longer follow-up period were associated with less satisfactory results. On multivariate analysis, only BMI and scar visibility maintained a significant association with cosmesis. BMI and scar visibility are the only factors significantly associated with cosmetic results of breast cancer conservative treatment, as evaluated by an international consensus panel.     

Cosmetic results after wire-guided biopsy of benign breast lesions

Background: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT).

Study Design: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy.

Results: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT.

Conclusions: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.     

The unsatisfactory margin in breast cancer surgery

BACKGROUND: Surgical margin involvement with breast cancer usually results in obligatory reexcision or mastectomy. While unalterable occult host and pathologic factors may interfere with margin clearance during the initial excision, it is possible that alterations in surgical technique might increase the likelihood of obtaining satisfactory margins. METHODS: Two hundred and thirty-five patients who were candidates for breast conservation therapy were identified for 1991 and 1996 using the Tumor Registry. Margins were defined as "unsatisfactory" if there was microscopic involvement with tumor or the margin was close at initial excisional biopsy and the surgeon opted for reexcision. Multiple logistic regression analyses of factors associated with margin status were performed. RESULTS: One hundred thirty-two (56%) patients had positive or close (unsatisfactory) margins; this rate increased from 51% in 1991 to 59% in 1996. Patients with unsatisfactory margins underwent more procedures (mean 2.0 versus 1.2; P <0.0001) than patients whose margins were satisfactory. The breast conservation rate for patients with unsatisfactory margins was 64% compared with 99% for patients with satisfactory margins. A multiple logistic regression demonstrated that patients with unsatisfactory margins were 67 times more likely to have a mastectomy than patients whose margins were satisfactory after adjusting for other significant factors (P <0.0001). The practice of fine needle aspiration biopsy, orientation of specimen margins by the surgeon, and reexcision of tumor at the first operation were statistically significant technical factors in obtaining satisfactory margins. Significant pathology factors were extensive intraductal component (EIC), lobular or ductal extension, and tumor size. CONCLUSION: These data show that technical factors in the surgical management of breast cancer, as well as biological factors such as EIC, can influence the success of breast conservation.     

Factors determining shape and symmetry in immediate breast reconstruction

Although a number of studies compare different techniques of breast reconstruction there seems to be a paucity of information documenting the factors that affect breast shape and symmetry after immediate reconstruction. A photographic analysis by 5 plastic surgeons (who were blinded to the nature of the procedure) of 62 patients undergoing skin-sparing mastectomy and immediate reconstruction was undertaken in an endeavor to identify these factors. Autologous techniques used included deepithelialized pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps (n = 23; in 9 patients a bilateral breast reduction using inverted-T keyhole skin markings was performed, and the TRAM flap was used to fill the reduced skin pocket) and 4 patients had extended latissimus dorsi flaps. Prosthetic reconstruction was undertaken in 35 patients in whom a bilateral breast reduction skin pattern was used in 23 (prosthesis inserted submuscularly in 5 patients and subcutaneously in 18 patients) or, in another 12 patients the skin envelope was retained and the prosthesis was inserted partially submuscularly in 7 patients and subcutaneously in 5 patients. As a total group, the results of autologous reconstruction were better than prosthetic reconstruction (P = 0.048, Mann-Whitney U test). However, when a breast reduction pattern was used and the prosthesis was inserted subcutaneously, the results were not significantly better than when the reduced skin envelope was filled by autologous tissue (P = 0.64, Mann-Whitney U test). Failure to replace the areola leads to a smaller reconstructed breast and asymmetry. The skin envelope, when retained in toto, seems to be a major factor affecting breast shape. In patients with a reduction pattern applied, the skin envelope again seems to be a major factor affecting shape, because the results are similar whether the envelope was filled with autologous tissue or prosthetic material. The neoparenchyma is an important factor affecting breast projection. In patients undergoing prosthetic reconstruction, the results were significantly better with subglandular placement compared with submuscular placement (P = 0.007, Mann-Whitney U test). Patients who developed a complication (requiring debridement in the operating room or that took more than a month to achieve healing) had a poorer cosmetic result (P = 0.015, Mann-Whitney U test). These factors need to be considered when planning breast reconstruction to optimize the aesthetic result.     

Bronchial fistula postpneumonectomy: predictive factors

OBJECTIVE: To determine predictive factors of bronchial fistula following pneumonectomy. PATIENTS AND METHODS: In 14 years (1989-2003), we collect 58 cases of bronchial fistula following 725 consecutive pneumonectomy in the service of thoracic surgery of the Sainte Marguerite Hospital in Marseilles. There were 53 cases (91.4%) of cancers and 5 cases (8.6%) of various pathology. The average age of the patients was of 61 +/- 10 years (range 24 to 80 years). The sex ratio M/F was 8.7. The software of regression SPSS (version11.5) was used to identify the factors risk of a bronchial fistula after a univariate and multivariate analysis. RESULTS: The prevalence of the bronchial fistula after a pneumonectomy was 8%.The preoperative factors which increased to a significant degree the incidence of the bronchial dent to the univariate analysis were the chronic smoking (P < 0.001), the existence of COPD (P = 0.001) and of a previous thoracic surgery (P = 0.01). Operational data like a right- side pulmonary resection (P < 0.001), the type of bronchial stup carried out (P = 0.03) as and an extended pneumonectomy to the auricule (P = 0.03) were significant risk factors. With the logistic regression the significant risk factors were the chronic smoking (P = 0.002), the existence of COPD (P = 0.003), a previous pulmonary surgery (P = 0.03) and the right - side of the pneumonectomy (P < 0.001). The indication of the pneumonectomy was retained neither by the univariate analysis, nor by the logistic regression significant risk factors. CONCLUSION: The predictive factors of a bronchial fistula after a pneumonectomy are dominated by respiratory co-morbidities. To prevent this complication, we insist on the stop of the tobacco, a better respiratory preparation and the acquisition of a protocol adapted of the bronchial stub after a pneumonectomy particularly on the right side.     

肝移植术后急性肾功能衰竭危险因素分析

目的 探讨围手术期因素对肝移植术后急性肾功能衰竭的发生的影响。方法 回顾性分析我院移植中心1999--2002年之间的资料齐全的89例肝移植患者的围手术期病例资料，利用单因素Logistic回归分析筛选肝移植术后急性肾功能衰竭的相关因素。结果 在单因素分析中患者的术中输血量及手术时间与患者术后急性肾功能衰竭的发生有相关性（P=0．041，P=0．005）。患者术后30d内的不良预后与急性肾功能衰竭的发生有相关性。在多因素分析中，仅有手术时间与术后急性肾功能衰竭的发生相关（P=0．026）。结论 术中输血量和手术时间为发生肝移植术后急性肾功能衰竭的危险因素，其中手术时间为一独立危险因素。     

全髋关节置换术后伤口愈合不良危险因素分析

目的探讨全髋关节置换术后患者切口愈合不良的相关危险因素,为临床决策提供指导。 方法回顾性分析2017年1月至2019年7月西安交通大学第二附属医院骨关节外科收治的单侧、新发股骨颈骨折、髋关节关节炎及股骨头坏死等并行单侧全髋关节置换或翻修患者,排除合并肿瘤、严重营养不良、经治疗后血糖、血压不能达到标准、合并凝血功能障碍或其他血液系统疾病、近期感染病史及局部皮肤条件较差的患者。根据术后是否发生伤口愈合不良分为两组。比较两组患者之间年龄、性别、身体质量指数(BMI)、术前白蛋白水平、糖尿病、高血压、长期激素应用史、术区多次手术史、手术时间、术前抗凝、术中皮下电刀止血、术后24 h引流量、术后是否输血等相关因素对伤口愈合的影响,应用R语言及Empower Stats统计软件对数据进行分析。依据数据类型,组间比较采用独立样本t检验或卡方检验;利用多因素logistic回归对不同危险因素进行分析,计算各因素比值比(OR)及95%置信区间(CI)。 结果本研究共纳入研究对象432例,其中术后发生伤口愈合不良事件患者43例。年龄(t＝2.907,P<0.05)、BMI(t＝15.399,P<0.001)、糖尿病(χ²＝111.86,P<0.001)、术区多次手术(χ²＝50.135,P<0.001)、长期激素应用史(χ²＝144.31,P<0.001)、手术时间(t＝12.334,P<0.001)及术后是否输血(χ²＝88.725,P<0.001)在两组之间差异有统计学意义。将单因素分析中差异有统计学意义的因素及术前白蛋白水平、皮下电刀止血等纳入多因素logistic回归分析中发现,年龄[OR＝1.784,95% CI＝(1.254,2.234),P＝0.006]、BMI [OR＝2.587,95%CI＝(1.647,4.950),P＝0.016],手术时间[OR＝8.643,95%CI＝(2.331,15.471),P＝0.001]及术区多次手术[OR＝3.218,95%CI＝(2.461,4.339),P＝0.041]是全髋关节术后发生伤口愈合不良的独立危险因素。 结论高龄、肥胖、手术时长及术区多次手术是全髋关节置换术后伤口愈合不良发生的独立危险因素,对存在有这些因素的患者,应早期诊断治疗。     

Oncoplastic technics with nipple-areolar complex resection for the treatment of central breast cancers

Central breast cancer has long been an indication for mastectomy. Plastic surgical techniques adapted to cancer (oncoplastic surgery) have made it possible to offer breast cancer patients conservative surgery with resection of the nipple-areolar complex (NAC). We evaluated carcinologic results and cosmetic outcomes as a function of the oncoplastic technique used. We performed a retrospective study in 47 patients with central breast cancers undergoing breast-conserving with NAC resection. Carcinologic results were assessed by calculating local and metastatic recurrences rates. Cosmetic results were evaluated on four criteria assessed by the patient then by two surgeons. The mean age of the patients was 59.8 (44-84) years. The mean tumour diameter was 17.4 (6-39)mm. Histological involvement of the nipple is present in 53% of the cases. No local recurrence, neither death was observed at 4.5 years median follow-up. One patient had liver metastatic recurrence at 83 months. Cosmetic results were assessed in 33 patients. Round-block provided better aesthetic results: the shape of the breast was considered very good or satisfactory for 90% of the surgeons with the round-block technique and for 46% with transverse incision (P=0.02). Breast-conserving surgery is feasible in selected patients with T1 or T2 central breast cancers, with no impact on the risk of local recurrence. NAC resection is essential especially when the patients have clinical signs of nipple involvement. It provides satisfactory cosmetic results, especially with the round-block technique, possibly associated with nipple reconstruction using the "cat-design" technique developed by our team.     

肿瘤大小对保留乳房手术后美容效果的影响

目的探讨肿瘤大小对保乳术后美容效果的影响。方法对1999年9月至2005年9月，肿瘤大小明确的170例保乳患者美容效果进行评价。结果术后患者美容效果满意率为84％（143／170）。当肿瘤直径大小〉3cm时，美容效果满意率为45．5％：肿瘤直径大小≤3cm时，满意率为86．8％。二者具有明显的统计学差异（P〈0．05）。结论肿瘤大小是影响术后美容效果的重要因素。     

乳腺癌根治术与保乳术对患者治疗效果的比较分析

目的 比较接受根治术或保乳术治疗的早期乳腺癌患者间的差异,为患者选择根治术或保乳术治疗乳腺癌提供合理依据.方法 回顾性分析宝鸡市第三人民医院普外科2009年1月-2012年1月收治的477例乳腺癌患者的病例资料,根据手术方法的不同,将其分为观察组(229例,48％)和对照组(248例,52％),其中观察组进行保乳术治疗,对照组进行根治术治疗,采用SPSS15.0统计学软件分析比较这两组患者复发率、术后并发症发生率、生存质量、乳房美容效果以及远期疗效等指标.结果 观察组患者的并发症发生率低于对照组(P＜0.05),但患者的l、3年内复发率与转移率与对照组相比,两组间差异无统计学意义(P＞0.05);观察组患者的生存质量与对照组相比差异具有统计学意义(P＜0.05);观察组美容效果的优良率达78.16％,明显高于对照组61.29％,差异具有统计学意义(x2=5.86,P＜0.05);两组用于衡量远期疗效的两项指标:总生存期(x2=3.154,P＞0.05)和无疾病进展生存期(x2=4.243,P＞0.05)间的差异无统计学意义.结论 在不影响患者术后复发率、转移率以及远期疗效的前提下,接受保乳术治疗的患者与接受根治术治疗的患者相比,具有并发症发生率低、美容效果好、生存质量高等显著优势.与传统根治术相比较,保乳术不失为一项明智的选择.     

股疝患者急诊手术的危险因素分析

目的探讨股疝患者急诊手术的相关危险因素。 方法回顾性分析2013年1月至2018年1月,中信惠州医院行股疝手术病程超过1个月103例患者的临床资料。根据手术时机分为急诊手术组（53例）和择期手术组（50例）。对2组患者的临床指标进行单因素分析,将单因素分析中具有统计学意义的因素纳入多因素Logistics回归分析,以确定其是否为股疝急诊手术的独立危险因素。 结果单因素分析结果显示,2组间年龄、病程、肝硬化、高血压和慢性阻塞性肺疾病比较,差异均有统计学意义（P<0.001、0.004、0.002、0.036、0.001）。Logistic多因素回归分析显示,年龄、病程、肝硬化和慢性阻塞性肺疾病是急诊手术的独立危险因素（OR=1.062、1.099、11.408、5.558,P=0.026、0.016、0.034、0.042）。 结论高龄、病程较长、合并肝硬化和合并慢性阻塞性肺疾病对病程超过1个月的股疝患者的手术时机选择的影响不容忽视。     

Bilirubin appears to be the only independent variable affecting mortality on liver transplant waiting list if waiting time exceeds 1 year

BACKGROUND: The Model for End-Stage Liver Disease (MELD) score has been shown to be the best predictor of short-term mortality on the liver transplant waiting list in the United States but waiting time often exceeds 1 year in many countries. We wanted to identify the factors affecting mortality on the liver transplant waiting list in Singapore where waiting time for liver transplant exceeds 1 year. PATIENTS AND METHODS: All patients who were listed on the liver transplant waiting list in Singapore from January 1997 to December 2003 excluding those who were transplanted were analyzed. MELD was calculated according to the United Network for Organ Sharing formula. Univariate analysis was performed to identify factors affecting mortality on the waiting list and multivariate analysis by logistic regression. Categorical and continuous variables were compared with the chi-square and Mann-Whitney U tests. RESULTS: There were 48 patients in the study. We found that on univariate analysis, bilirubin, INR, MELD score, and Child's score significantly influenced mortality on the waiting list but on multivariate analysis, bilirubin was the only independent prognostic indicator of mortality on the waiting list (LR = 1.97; 95% confidence interval = 1.08 to 3.61). INR was found to be significantly correlated to bilirubin with Pearson correlation (R = 0.63, P < .001). CONCLUSION: Bilirubin is the only independent factor affecting mortality on the liver transplant waiting list where waiting time exceeds 1 year.     

Predicting blood transfusion factors in coronary artery bypass surgery

OBJECTIVE: Blood conservation has become one of the most important issues in cardiac surgery. We clarified preoperative predictors of the need for blood transfusions during coronary artery bypass graft surgery. METHODS: Subjects were 89 patients--66 men (74%) and 23 women (26%) 40 to 84 years old (mean: 66.2 +/- 8.3 years)--undergoing isolated coronary artery bypass surgery from September 1997 to December 1999. Of these, 66 patients (74%) received transfusion during hospitalization and 23 (26%) did not. Nine risk factors detected by univariate study were entered in a multivariate logistic regression model of the relationship between preoperative variables and blood transfusion. RESULTS: Independent predictors were emergency surgery (P = .0023), lower hematocrit (P = .0027), older age (P = .0043), and the presence of peripheral vascular disease (P = .0070). Optimal cutoff of hematocrit for blood transfusion was 39% and age 64 years via receiver-operating characteristics curves based on the relation between sensitivity and specificity. CONCLUSION: Patients older than 64 years with hematocrit less than 39% and/or peripheral vascular disease should be treated routinely using preoperative storage of autologous blood whenever the patient's condition permits. For patients undergoing emergency surgery, further studies are required, including lowering transfusion threshold and using determinants other than hematocrit.     

Factors related to post-liver transplantation acute renal failure

Acute renal failure (ARF) after liver transplantation (OLT) is a common complication with severe impact on early and late prognosis of recipients. Factors predicting its incidence have not been fully identified due to the lack of a universal standard as well as the variance of data between transplant centers. To identify factors related to post-OLT ARF, we retrospectively collected materials on 89 patients, who underwent OLT from 1999 to 2001 in our center. Factors associated with post-OLT ARF were identified using univariate logistic regression. Significant factors were then entered into a multivariate logistic regression to identify factors independently associated with post-OLT ARF. Upon univariate analysis, intraoperative volume of blood transfusion (P = .041) and duration of operation (P = .005) were significant. ARF was associated with a poor prognosis (P < .001). Only duration of operation (P = .026) was an independent factor predicting the development of ARF. In conclusion, intraoperative volume of blood transfusion and duration of operation were factors contributing to post-OLT ARF in which the duration of the operation was an independent risk factor. The incidence of post-OLT ARF greatly increased recipient mortality in the early postoperative period.     

预测乳腺癌术后切口愈合不良的列线图模型建立

目的探讨乳腺癌术后切口愈合不良的危险因素,构建预测术后切口愈合不良发生的列线图模型,并评估模型的预测效果。 方法采用便利抽样法,选择2016年1月至2021年10月徐州医科大学附属淮安医院行乳腺癌手术的813例患者,根据术后切口愈合情况分为愈合良好组（767例）和愈合不良组（46例）。收集两组患者基本信息、病理特征及手术情况开展单因素分析,通过多因素Logistic回归分析筛选术后切口愈合不良的危险因素,利用R 4.1.3软件绘制术后切口愈合不良发生的列线图预测模型并评估其区分度和符合度。 结果愈合不良组年龄、营养不良、合并糖尿病、贫血及手术切口为纵切口比例、置引流管时间与愈合良好组比较,差异均有统计学意义（P<0.05）。Logistic回归分析显示,乳腺癌术后切口愈合不良发生的主要危险因素为年龄大（OR=1.269）、营养不良（OR=2.376）、合并糖尿病（OR=2.262）、贫血（OR=2.227）、置引流管时间长（OR=1.571）（均P<0.05）;受试者工作特征曲线及校准曲线分析结果显示,构建的列线图预测模型区分度（曲线下面积为0.785,95% CI：0.725~0.845）及符合度（拟合优度HL检验χ²=8.294,P=0.405）均较高。 结论基于年龄、营养不良、合并糖尿病、贫血、置引流管时间5项危险因素构建的乳腺癌术后切口愈合不良列线图模型具有较好的预测效能。     

Evaluation of functional outcome of the floating knee injury using multivariate analysis

INTRODUCTION: The objective of this study is to evaluate significant contributing factors affecting the functional prognosis of floating knee injuries using multivariate analysis. PATIENTS AND METHODS: A total of 68 floating knee injuries (67 patients) were treated at Kitasato University Hospital from 1986 to 1999. Both the femoral fractures and the tibial fractures were managed surgically by various methods. The functional results of these injuries were evaluated using the grading system of Karlstr?m and Olerud. Follow-up periods ranged from 2 to 19 years (mean 50.2 months) after the original injury. We defined satisfactory (S) outcomes as those cases with excellent or good results and unsatisfactory (US) outcomes as those cases with acceptable or poor results. Logistic regression analysis was used as a multivariate analysis, and the dependent variables were defined as a satisfactory outcome or as an unsatisfactory outcome. The explanatory variables were predicting factors influencing the functional outcome such as age at trauma, gender, severity of soft-tissue injury in the femur and the tibia, AO fracture grade in the femur and the tibia, Fraser type (type I or type II), Injury Severity Score (ISS), and fixation time after injury (less than 1 week or more than 1 week) in the femur and the tibia. RESULTS: The final functional results were as follows: 25 cases had excellent results, 15 cases good results, 16 cases acceptable results, and 12 cases poor results. The predictive logistic regression equation was as follows: Log 1-p/p = 3.12-1.52 x Fraser type - 1.65 x severity of soft-tissue injury in the tibia - 1.31 x fixation time after injury in the tibia - 0.821 x AO fracture grade in the tibia + 1.025 x fixation time after injury in the femur - 0.687 x AO fracture grade in the femur ( p=0.01). Among the variables, Fraser type and the severity of soft-tissue injury in the tibia were significantly related to the final result. CONCLUSION: The multivariate analysis showed that both the involvement of the knee joint and the severity grade of soft-tissue injury in the tibia represented significant risk factors of poor outcome in floating knee injuries in this study.     

Clinical and histological factors associated with sentinel node identification in breast cancer

BACKGROUND: Although sentinel lymph node biopsy is likely to be offered as a method of assessing nodal status in primary breast cancer, the inability to identify the sentinel node at the time of surgery will limit the number of patients who may benefit from the procedure. The purpose of the present study was to identify factors that are associated with intraoperative identification of the sentinel node(s). METHODS: Between September 1995 and May 1999, lymphatic mapping using a combination of preoperative lymphoscintigraphy and/or blue dye was performed on 169 consecutive patients with clinically lymph node-negative primary operable breast cancer. Clinical and histological factors were assessed using univariate and multivariate analysis to determine those that were associated with intraoperative identification of the sentinel node. RESULTS: The sentinel node was identified at the time of surgery in 142 cases (84%). Of the clinical factors assessed, preoperative identification of the sentinel node on lymphoscintigraphy (P < 0.0001), use of blue dye in combination with isotope (P = 0.001), symptomatic palpable tumours (P < 0.05) and the experience of the surgeon (P = 0.03) were significant in identifying the sentinel node at operation. No histological factor was associated with intraoperative identification of the sentinel node. Using multivariate analysis, positive identification of the sentinel node on lymphoscintigram, the experience of the surgeon and the use of both blue dye and isotope for sentinel node mapping were independent factors associated with intraoperative sentinel node identification. The lymphoscintigram result was the strongest independent factor according to its beta value, a measure of the weight of significance. CONCLUSION: Patients undergoing sentinel lymph node mapping and biopsy should be warned of the possibility of failure of sentinel node identification at operation. Our results suggest that the best predictor of intraoperative sentinel node identification is the visualization of the sentinel node on preoperative lymphoscintigraphy. The result of the lymhoscintigram may allow for additional preoperative counselling of the patient regarding the success or failure of sentinel node biopsy. Technical factors such as the experience and diligence of the surgeon, as well as the sentinel node mapping technique, are also important in determining the success of the procedure.     

Thoracic paravertebral block for breast surgery

Cosmetic and reconstructive breast augmentation is a frequently performed surgical procedure. Despite advances in medical treatment, surgical intervention is often associated with postoperative pain, nausea, and vomiting. Paravertebral nerve block (PVB) has the potential to offer long-lasting pain relief and fewer postoperative side effects when used for breast surgery. We compared thoracic PVB with general anesthesia for cosmetic breast surgery in a single-blinded, prospective, randomized study of 60 women scheduled for unilateral or bilateral breast augmentation or reconstruction. Patients were assigned (n = 30 per group) to receive a standardized general anesthetic (GA) or thoracic PVB (levels T1-7). Procedural data were collected, as well as verbal and visual analog pain and nausea scores. Verbal postoperative pain scores were significantly lower in the PVB group at 30 min (P = 0.0005), 1 h (P = 0.0001), and 24 h (P = 0.04) when compared with GA. Nausea was less severe in the PVB group at 24 h (P = 0.04), but not at 30 min or 1 h. We conclude that PVB is an alternative technique for cosmetic breast surgery that may offer superior pain relief and decreased nausea to GA alone. Implications: Paravertebral nerve block has the potential to offer long-lasting pain relief and few postoperative side effects when used for breast surgery. We demonstrated that paravertebral nerve block, when compared with general anesthesia, is an alternative technique for breast surgery that may offer pain relief superior to general anesthesia alone.     

超声引导下Mammotome旋切术用于早期乳腺癌治疗的临床效果

目的:探讨超声引导下Mammotome旋切术用于早期乳腺癌的临床效果。方法:收集2015年1月—2018年6月接受超声引导下Mammotome旋切术完全切除病灶,术后病理确诊为早期乳腺癌并接受根治手术的患者51例患者资料,分析残腔边缘肿瘤残留情况及残腔肿瘤残留的危险因素。结果:51例患者中15例(29.4%)有肿瘤残留。确诊为乳腺癌后,37例患者接受乳房切除术,14例患者接受保乳根治术并切除针道,病理提示14例患者的针道中均未见癌细胞残留。单因素分析结果显示,乳腺癌病史,肿瘤组织学类型,组织学分级,激素受体及腋窝淋巴结状态对肿瘤残留无影响(均P0.05);肿块直径(P=0.046),年龄(P=0.036)和Ki-67高表达(P=0.039)与肿瘤残留有关。多因素分析发现Ki-67高表达是独立的危险因素(OR=4.83,P=0.038)。结论:超声引导下Mammotome旋切术切除早期乳腺癌存在较高的肿瘤残留率,故须严格控制适应证来降低残留率,但其临床应用价值需进一步评估。