Sentinel lymph node biopsy performed under local anesthesia is feasible

BACKGROUND: A sentinel lymph node (SLN) biopsy in breast cancer patients, performed under local anesthesia (LA), could have advantages such as more efficient use of operating room time and pathologist time. It also provides a histologic diagnosis before definitive breast surgery is undertaken. The aim of this study was to assess feasibility by comparing the results of SLN procedures performed under LA versus general anesthesia (GA). METHODS: The SLN procedure was performed in 50 consecutive outpatients and 167 inpatients with clinical T1-2N0 breast cancer while they were under LA and GA, respectively. The SLN detection rate, a comparison of mapped and harvested SLNs, was compared for both groups. The duration of the SLN biopsies performed under LA was also measured. RESULTS: For both groups a median of 2 SLNs/patient were harvested. The detection rate was 1.00 for the LA group and 0.99 for the GA group. The learning curve for SLN procedures under LA showed a decrease in duration for the consecutive months (not significant). CONCLUSIONS: SLN biopsy can be safely and adequately performed with the patient under LA. It allows early diagnosis of the lymph node status, acquired on an outpatient basis, with minimal discomfort to the patient. The learning curve demonstrated that the LA procedure can quickly be mastered if the surgeon is experienced in performing SLN biopsies.     

乳腺癌患者的局麻下前哨淋巴结活检

1 引 言 乳腺癌治疗概念已经从最大可耐受治疗转变为最小有效治疗.从腋窝淋巴结切除(ALND)转变为前哨淋巴结活检(SLNB).如果远处转移的癌细胞已经播散到腋窝淋巴结则乳腺癌播散到腋窝淋巴结这一主流理论被确定.接受来自肿瘤的淋巴管引流的第一个淋巴结称为前哨淋巴结.我们可以发现前哨淋巴结并且检测它是否存在癌细胞.如果前哨淋巴结没有癌症,那就没必要切除其余剩下的腋窝淋巴结.这种找到前哨淋巴结的方法就是注射异硫蓝染料或放射同位素进入乳腺区域然后仔细解剖找到第一个淋巴结并将前哨淋巴结移送病理学家通过冷冻切片来鉴定.如果这没有远处转移的癌细胞存在于淋巴结中,外科医师可以不用处理腋窝淋巴结(ALND).     

Effectiveness and reliability of sentinel lymph node biopsy under local anesthesia for breast cancer

The objective of the present study was to determine the effectiveness and reliability of sentinel lymph node biopsy (SLNB) performed under local anesthesia (LA) for patients with breast cancer, by comparing the results with those obtained under general anesthesia (GA). Between January 2006 and February 2007, SLNB was performed under LA or GA in 37 and 94 patients with clinical Tis, T1, T2 or T3 N0 breast cancer, respectively. All underwent radiocolloid and blue dye injections to identify sentinel nodes. The sentinel node detection rate, the number of nodes harvested and the number of positive nodes were compared between the two groups. The sentinel node identification rates were similar for both groups. The number of sentinel and axillary nodes removed and number of positive nodes did not differ significantly between the two groups. SLNB performed under LA is an effective and reliable alternative to SLNB done under GA.     

A simplified open gastrostomy under local anesthesia

Revision of the standard gastrostomy is often necessary in patients with neuromuscular disorders. These patients pose many anesthetic risks that frequently preclude the use of general anesthesia, intravenous sedation, or endoscopy. Modification of the Stamm gastrostomy enables it to be performed comfortably and readily under local anesthesia. The modification proposed passes the gastrostomy tube through the omentum en route to the abdominal wall. This ensures a seal to the surgical site, eliminates the need for tacking sutures, and allows for a smaller midline incision. These factors greatly reduce the discomfort of the procedure allowing it to be easily accomplished under local anesthesia. This technique of open gastrostomy under local anesthesia has been used in more than 35 patients over the past 10 years with no documented leaks.     

Patient acceptance of local anesthesia for breast biopsy.

Three out of every four patients undergoing breast biopsy found the outpatient local-anesthesia method acceptable in this study. Patient acceptance was greater among those who experienced less pain and anxiety. This suggests that acceptance could be increased by more complete preoperative explanation to the patient, adequate premedication, properly administered local anesthesia and gentle technique. Acceptance would also probably be far greater in a private practice setting than in the instititutional and sometimes impersonal setting of a large federal hospital. Breast biopsy under local anesthesia has not compromised survival rates or increased local recurrence. When it is done on an outpatient basis, hospital costs have been reduced at least threefold. It is apparent, then, that patient objection is not a deterrent to the use of breast biopsy under local anesthesia on an outpatient basis. For patients with dominant breast masses, this modality can be added to any plan of management which seeks to reduce patient risk and inconvencience, diminish hospital costs and alleviate bed demand all without impairing diagnostic accuracy or long-term survival.     

Nonpalpable breast lesions: Mammographic wire-guided biopsy and radiologic-histologic correlation

During a 1-year period, 2,909 symptomatic women were referred for physical examination of the breast and mammography. In 44 women (1.5%), mammography discovered a total of 45 impalpable breast lesions that might represent an early cancer. Mammographic wire-guided biopsy was performed using a self-retaining hook wire for the marking of the lesion. The radiographic localization was facilitated by using a perforated compression plate with holes visible on the mammograms. The biopsy method showed high precision and accuracy. Only 1 guide wire was needed in each instance. In 96% of cases, the wire transfixed the lesion or was placed in close proximity (within 1 cm) to the lesion. Correct biopsy was achieved in all instances, but in some cases more than 1 biopsy was necessary. The malignancy rate was 29% of biopsies and 30% of patients. The metastatic rate to axillary lymph nodes was 17%. Generally, the histologic pattern showed great variety with several different components in most specimens. The radiologic-histologic correlation is tabulated and the significance of preclinical breast cancer detection is emphasized. The biopsy method described is reliable and highly recommended. We found the procedure easy to handle and time-saving. The method was fully acceptable to patients and the cosmetic results were excellent.

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Résumé Au cours d'une année nous avons été amenés à examiner les seins de 2909 femmes par examen clinique et mammographie alors qu'elles se plaignaient d'une atteinte mammaire. Chez 44 d'entre elles (1,5 pour cent) la mammographie a permis de déceler 45 lésions impalpables susceptibles d'Être de nature néoplasique. La biopsie fut pratiquée systématiquement en s'aidant d'un repère métallique inséré au niveau de la lésion par un procédé particulier. En effet nous avons pratiqué la mammographie en comprimant le sein avec une plaque perforée d'orifices visibles sur les clichés puis en introduisant le repère au niveau de la zone suspecte. La méthode s'est montrée d'une grande précision. Dans 96 pour cent des cas le repère fut placé à moins d'un centimètre de la lésion et la biopsie fut toujours possible encore que parfois il ait fallu procéder à plusieurs prélèvements.Le taux de lésions malignes s'est élevé à 29 pour cent des biopsies pratiquées et 30 pour cent des malades examinées. Les ganglions axillaires étaient déjà envahis dans 17 pour cent des cas. Les types histologiques des lésions découvertes se sont montrés très variables et composés d'éléments cellulaires différents.A la suite de cette étude une corrélation radiologique et histologique a pu Être établie et la valeur de la méthode pour découvrir le cancer du sein a son début a pu Être démontrée.

     

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.     

Office-based surgery and anesthesia

Health care delivery is undergoing a revolutionary change. It is focusing rapidly all over the world towards outpatient and home care. One of the most obvious results of these changes has been the relative explosion office-based surgery and anesthesia; however, these are not new concepts. Dentistry and office-based anesthesia have always been closely intertwined. In 1844, two dentists, Wells and Morton, changed the practice of anesthesia firstly with the use of nitrous oxide and secondly with ether for tooth extraction. Thereafter, office-based surgery and anesthesia continued to evolve. In the past two decades, the rapid development of new surgical technologies and pharmaceuticals have facilitated the movement of more invasive surgical procedures and anesthesia to less invasive settings, such as the doctor's office. The most significant recent changes in health care are changes in the consumer, the practitioner and the provider. All are demanding high quality anesthesia and surgery care at a reduced cost. Articles describing almost every type of surgical and anesthetic techniques in the office can be found in the literature. However, the success of providing safe and cost-effective surgical and anesthetic care at an office depends on major issues, including adequate selection of the surgical procedure, complete preoperative assessment of the patient's state of health and adequate equipment and design of the unit. It is incumbent upon practitioners to make certain that the safety of the hospitals is not sacrificed in the office setting. Health care has to be delivered as safely in the office as it would be elsewhere. Regulations and guidelines should be established in consultation with surgeons, anesthesiologists and administrators to ensure safe health care. These guidelines should be based on the specific type of surgery, the level of anesthetic required and the design of the office. This way the provision of adequate quality of care is ensured. Office-based anesthesia and surgery will no doubt continue to evolve because it is safe, pleasing and convenient for the patient and of low cost.     

Simple and effective local anesthesia for transperineal extended prostate biopsy: Application to three-dimensional 26-core biopsy

Abstract:   We developed a local anesthetic procedure for three-dimensional 26-core prostate biopsy (3D26PBx), a combination of transperineal 14-core biopsy (TP14PBx) and transrectal 12-core biopsy (TR12PBx). At first, a periapical triangle, confined by the levator ani, the rhabdosphincter and the external anal sphincter muscle, was made visible by transrectal ultrasound. After administration of 1 mL of 1%-lidocaine into the midline perineal skin 1.5 cm above the anus, we inserted a spinal needle toward the periapical triangle for injection of 1.5–2.0 mL of 1%-lidocaine and performed the TP14PBx. After administration of the periprostatic nerve block with 10 mL of 1%-lidocaine, we performed the TR12PBx. The efficacy of the procedure was evaluated prospectively in 45 consecutive men undergoing the 3D26PBx. The 3D26PBx was completed with just local anesthesia in all patients. The pain levels, assessed by an 11-point visual analog scale, were not different between the TP14PBx and the TR12PBx.     

Thoracoscopic pleural biopsy for tuberculous pleurisy under local anesthesia.

OBJECTIVE: We directly examined the thoracic cavity by thoracoscopy under local anesthesia, performed pleural biopsy, and made a definitive pathological diagnosis in tuberculous pleurisy. SUBJECTS AND METHODS: We performed a retrospective study of 32 patients who had been bacteriologically and pathologically diagnosed with tuberculous pleurisy by thoracoscopy under local anesthesia in our hospital between January 1995 and November 2004. RESULTS: Bacteriological examination of pleural fluids obtained by thoracentesis before examination showed that one sample was polymerase chain reaction (PCR)-positive, and 5 samples were culture-positive. Bacteriological examination of pleural fluids obtained by thoracoscopy revealed that 2 samples were PCR-positive, and 5 samples culture-positive, including 2 preoperatively positive samples. The adenosine deaminase (ADA) levels ranged from 18.3 to 279.0 U/L, with a mean of 72.9 U/L, including 50 U/L or less in 5 patients and 35 U/L or less in 3 patients. Thirty patients (93.8%) were successfully diagnosed by pleural biopsy with pathological examination, and 21 (65.6%) of them by pathological examination alone. CONCLUSION: In patients with suspected tuberculous pleurisy, thoracoscopic pleural biopsy under local anesthesia should be actively performed, because the technique has a high diagnostic rate, and can be easily and safely performed.     

Efficacy and cost analysis of transrectal ultrasound-guided prostate biopsy under monitored anesthesia

Sedation may result in reduction in pain during transrectal ultrasound (TRUS)-guided prostate biopsies. We aimed to evaluate the efficacy and safety of a combination of propofol and remifentanil infusion during TRUS-guided prostate biopsy and the related increases in health care costs. From January to September 2010, 100 men undergoing a transrectal prostate biopsy were randomized into two groups. In Group 1, 50 patients received a combined infusion of propofol and remifentanil; in Group 2, 50 patients received lidocaine jelly. After TRUS-guided biopsies were performed, pain and patient satisfaction were evaluated by a 10-point visual analog scale (VAS), and a cost-related patient satisfaction questionnaire was completed by all patients. Patients were also asked whether they would be willing to undergo repeat biopsy by the same method. Patients in Group 1 showed a significantly lower VAS score than those in Group 2 (mean VAS score: 0.9±1.1 versus 6.3±2.5; P<0.001). In addition, the patient satisfaction scale was significantly higher in Group 1 (P=0.002). Although the overall cost was significantly higher in Group 1 (P=0.006), patient satisfaction scales considering cost were also higher in this group (P=0.009). A combination of propofol and remifentanil is a safe and effective way to decrease patient pain and increase patient satisfaction during TRUS-guided prostate biopsy. Although the costs were higher in the group that received sedation, as expected, the patients exhibited heightened satisfaction and willingness to repeat biopsies by the same method.     

Sentinel lymph node biopsy is successful and accurate in male breast carcinoma

BACKGROUND: Men and women with breast cancer have similar risks of morbidity related to axillary lymph node dissection (ALND). Sentinel lymph node (SLN) biopsy minimizes this risk. We report results from the largest series of SLN biopsies for male breast cancer and compare this experience with that of female counterparts treated concurrently. STUDY DESIGN: The Memorial Sloan-Kettering Cancer Center SLN biopsy database showed that 7,315 SLN biopsy procedures were performed for primary breast cancer from September 1996 to July 2005. Of these, 78 (1.0%) procedures were performed in men. Followup data were obtained from medical record review. RESULTS: SLN biopsy was successful in 76 of 78 (97%) patients. Negative SLNs were found in 39 of 76 (51%) patients. In 3 (8%) patients with negative SLNs, a positive non-SLN was found, identified by intraoperative palpation. Positive SLNs were found in 37 of 76 (49%) patients. In 22 of 37 (59%), node positivity was determined intraoperatively, prompting immediate ALND. In 15 of 37 (41%) patients with positive SLNs, node positivity was determined postoperatively. Of these 15, 9 (60%) underwent completion ALND. In the 2 of 78 (3%) patients with failed SLN biopsy procedures, ALND was performed and yielded positive nodes. At a median followup of 28 months (range 5 to 96 months), there were no axillary recurrences. Compared with their female counterparts, men with breast cancer had larger tumors and were more likely to have positive nodes. CONCLUSIONS: SLN biopsy is successful and accurate in male breast cancer patients. Although a larger proportion of men have positive nodes, for men with negative nodes, SLN biopsy may reduce morbidity related to ALND.     

Insertion under local anaesthetic of temporary electrodes for sacral nerve stimulation testing is reliable and cost effective

Aim The aim of this study was to determine whether temporary electrode implantation under local anaesthesia (LA), with reliance on sensory response rather than motor response, gives as good a result as implantation under general anaesthesia (GA). Method A retrospective review of a prospectively maintained database of patients with faecal incontinence treated with sacral nerve stimulation (SNS) was performed. Results A total of 111 consecutive patients underwent a 2‐week trial of SNS. Forty‐seven (42%) had the temporary electrode implanted under LA and 64 (58%) under GA. There was no significant difference between the two groups in relation to the improvement in Vaizey score (P = 0.15), incontinent episodes per day (P = 0.73) and incontinent episodes per week (P = 0.93). There was no significant difference (P = 0.14) in the percentage of successful trials between the LA group (64%) and the GA group (77%); however, only 62% of the GA group were discharged home on the same day when compared with 89% of the LA group (P < 0.0001). Conclusion Similar success rates for temporary trial with SNS can be achieved with LA and GA. Insertion under LA is associated with reduced cost, shorter hospital stay and quicker recovery, and it avoids the risk of general anaesthesia.     

局麻下开放腹膜前复发性腹股沟疝修补术的临床疗效

目的总结局部麻醉下,开放腹膜前复发性腹股沟疝修补术的临床疗效。 方法回顾性分析自2016年6月至2018年1月,陕西省第四人民医院普外科收治的36例成人复发性直疝患者。行局部麻醉下单纯腹膜前修补术,观察其手术时间、术后住院时间、术后疼痛、术后复发等数据。 结果本组患者平均手术时间为单侧26 min（19～36 min）,双侧46 min（39～65 min）。术后回病房即可饮食,术后局部腹带加压12～24 h,手术当天下床活动,住院期间伤口轻度疼痛,一般不用处理,平均住院2.8 d。术后1周内,脂肪液化者2例,血清肿者1例,无切口感染,无补片感染,无复发。 结论局部麻醉下,单纯腹膜前无张力修补复发性性直疝,安全可靠。     

Ureteroscopy under local anesthesia

Ureteroscopy has been performed with local anesthesia with and without sedation in 30 patients. Flexible endoscopes were used in 18, rigid endoscopes alone in 7, and rigid and flexible instruments in 5 patients. The flexible instruments ranged in size from 4F to 10F, while rigid instruments were 10F to 12F. Although most procedures were diagnostic, calculi were removed from the distal ureter in 4 patients and from the midureter in 1 patient. Ultrasonic lithotripsy was utilized in 1 patient. The success and tolerance of flexible or distal rigid ureteroscopy with local anesthesia permits its recommendation in carefully selected patients.