Axillary thoracotomy

The axillary thoracotomy should be the incision of choice for most uncomplicated general thoracic surgical procedures. It can be performed rapidly, avoids major muscle transection, and by employing a double lumen endotracheal tube will permit segmental resection as well as lobectomy without technical problem. One hundred consecutive, elective axillary thoracotomies were performed with minimal morbidity and only one mortality. Twenty-five of the patients were of high surgical risk. The larger posterolateral thoracotomy is reserved for repeat thoracotomy, Pancoast tumors, difficult procedures such as bronchoplasty and/or radical pneumonectomy, and when pleural symphysis is expected. Sometimes called lateral thoracotomy or mini-thoracotomy, the axillary thoracotomy is our most common incision.     

Axillary dissection

Axillary dissection remains an important aspect of breast cancer treatment. No other factor has been demonstrated to be of more prognostic significance in breast cancer than the presence or absence of axillary metastases.^12–14 An axillary sampling that excises fewer than 6 nodes is inadequate for staging and should not be substituted for a complete axillary dissection. Note that directed sentinel node biopsy is different than random axillary lymph node sampling, and these 2 procedures should not be confused. Generally, the pathologist will identify and examine some 15 to 25 nodes in an axillary dissection specimen. The absolute number of axillary nodes varies from individual to individual and with the diligence of pathological examination. Recently, it has been our practice to process the axillary nodes for permanent sections, allowing multiple levels of each node to be studied. Cytokeratin staining is also used selectively.As axillary dissection enters its third century, it must continue to provide complete staging information, combined with preservation of function and cosmetic acceptance. The impact of sentinel lymph node biopsy on axillary dissection is currently being defined.¹⁵ However, it is clear that precise, reliable axillary staging information will remain an indispensable part of surgery for primary breast cancer.^16,17     

Pigmented Axillary Nodule: Carcinoma of an Ectopic Axillary Breast

BACKGROUND: Ectopic mammary tissue appears in humans owing to an incomplete embryologic regression of the mammary ridges. The same pathology that affects normally positioned breasts, including carcinoma, can occur in ectopic mammary tissue. OBJECTIVE: The objective was to present the case of a 43-year-old woman who developed a ductal mammary carcinoma of ectopic breast tissue. METHODS: We describe the patient's history, the histologic diagnosis, and the therapy carried out. We also discuss the clinical differential diagnosis and current management options. RESULTS: The patient developed a ductal mammary carcinoma in the axilla, which is the most common site for the occurrence of carcinoma of ectopic breast tissue. She has been sucessfully treated with surgery, lymphadenectomy, radiotherapy, and chemotherapy. Accessory mammary tissue is a relatively frequent incidental finding, whereas carcinoma of ectopic tissue is very rare. CONCLUSIONS: Carcinoma occurring in ectopic breast tissue remains rare, but this diagnosis must be suspected when confronted with any axillary nodule. The prognosis is similar to carcinoma of normal breast in the same tumor, node, metastasis stage, although it has a higher rate of lymph node involvement. There is no consensus on the advisability of excising ectopic mammary tissue.     

Axillary nerve injury

Axillary nerve injury remains the most common peripheral nerve injury to affect the shoulder. It most often is seen after glenohumeral joint dislocation, proximal humerus fracture, or a direct blow to the deltoid muscle. Compression neuropathy has been reported to occur in the quadrilateral space syndrome, although the true pathophysiology of this disorder remains unclear. The axillary nerve is vulnerable during any operative procedure involving the inferior aspect of the shoulder and iatrogenic injury remains a serious complication of shoulder surgery. During the acute phase of injury, the shoulder should be rested, and when clinically indicated, a patient should undergo an extensive rehabilitation program emphasizing range of motion and strengthening of the shoulder girdle muscles. If no axillary nerve recovery is observed by 3 to 6 months after injury, surgical exploration may be indicated, especially if the mechanism of injury is consistent with nerve rupture. Patients who sustain injury to the axillary nerve have a variable prognosis for nerve recovery although return of function of the involved shoulder typically is good to excellent, depending on associated ligamentous or bony injury.     

Axillary Plexus Block

In axillary plexus blocks employed in surgical procedures involving the upper extremity, comparisons were made between anaesthesias produced by 2% mepivacaine (Carbocaine®) with epinephrine 1:200,000 and 0.25 and 0.5% LAC-43 (Marcaine®) with epinephrine 1:200,000, as to the effectiveness of the anaesthesia, duration of the anaesthesia, as well as the occurrence of post-operative pain with each drug. The series of 59 blocks was divided according to the anaesthetics used into three comparable groups. The intensity of anaesthesia in various cutaneous and motor branches of the axillary plexus was used as the criterion for success of the blocks. This anatomical criterion was also compared with operability. As regards latency there are no statistically significant differences between the agents. Mepivacaine as 2% solution + epinephrine was found to be definitely more efficient than 0.5 or 0.25% LAC-43 as regards the intensity of anaesthesia in various nerves. There were, however, no noteworthy differences in operability between mepivacaine and 0.5% LAC-43, but 0.25% LAC-43 proved to be unsatisfactory in this respect. The duration of both sensory and motor depression (anaesthesia) was prolonged more than twice with LAC-43 (both 0.5 and 0.25%). The pain caused by operative trauma appeared after 12 hours with 0.5% LAC-43 and after approx. 9 hours with 0.25% LAC-43 and after about 3 1/2 hours with 2% mepivacaine. There were no noticeable side effects or neurological complications.     

Axillary Artery to Contralateral Axillary Vein Graft Fistula in Chronic Hemodialysis Patients

Background.?Vascular access failure is a severe and common complication for hemodialysis patients. The possible vascular access sites are limited in dialysis patients. Axillary artery to contralateral axillary vein arteriovenous fistula (AVF) is one of the possibilities. However, the clinical outcome of this procedure is still un-defined. Object.?The purpose of this study is to review the clinical outcome of axillary artery to contralateral axillary vein AVF as a hemodialysis vascular access. Patients and Methods.?We retrospectively reviewed native or graft arteriovenous fistula records for chronic hemodialysis patients at Chang Gung Memorial Hospital in Kaohsiung, Taiwan, from 01 1986 to 03 2001. Records were reviewed for all chronic hemodialysis patients, with more than 2000 individuals receiving more than 10,000 fistulas. Eight patients received axillary artery to contralateral axillary vein AVF. Results.?The mean age for these patients was 61.7 ± 16.3 year-old at time of surgery. All patients had received multiple native or graft arteriovenous fistula creation. The 2-year and 4-year AVF graft survival is 87.5% and 43.8% respectively. One patients developed brachial plexopathy after operation. Another patient had venous hypertension distal to the AVF site. Both patients were managed conservatively. There is no AVF-related mortality in these patients. Conclusion. We conclude that axillary artery to contralateral axillary vein graft fistula may be a feasible alternative choice for chronic hemodialysis access.     

Primary Axillary Venous Aneurysm

We operated upon an 18-year-old female presenting a spontaneous aneurysm of the axillary vein. Pathologic examination of the aneurysm showed an anomalous muscular layer. To our knowledge, this is the first case of nontraumatic axillary venous aneurysm.     

Axillary Lymph Node Inclusions

Lymph node inclusions can occur in axillary lymph nodes, where they can mimic metastatic breast carcinoma. This article provides an overview of epithelial and nonepithelial lymph node inclusions, including mammary-type glandular inclusions, Mullerian-type glandular inclusions, squamous inclusions, mixed glandular-squamous inclusions, and nodal nevi. The discussion emphasizes the histologic and immunophenotypic features and differential diagnoses of each entity.