Breast-conserving surgery for non-palpable breast cancer: relationship of lumpectomy resection margins measurements between remote perioperative ultrasound and postoperative histopathology

Purpose: Tumour-free resection margins (RMs) are mandatory in breast-conserving surgery. On-site intraoperative ultrasound (US)-guided tumour resection with extemporaneous histopathological assessment of RMs has been described. Remote intraoperative US assessment of RMs is an alternative. The purpose of this study was to evaluate the relationship of lumpectomy RMs measurements between remote intraoperative US and postoperative histopathology.Methods and Materials: In a retrospective IRB-approved review of 100 consecutive lumpectomies performed between October 2009 and April 2011 for presumed non-palpable breast cancer, 71 women (mean age 63.8years) were included. Twenty-nine patients were excluded because of absence of cancer at histopathology and/or incomplete data. Measurements of lumpectomy minimal RMs and tumour maximal diameter obtained on remote intraoperative US and postoperative histopathology were compared.Results: Minimal RMs were 0.35±0.32 (mean±SD) and 0.35±0.32cm on remote intraoperative US and postoperative histopathology, respectively. No significant difference was found between these measurements (p=0.37). Tumour maximal diameter was 1.02±0.51 (mean±SD) and 1.33±0.74cm on remote intraoperative US and postoperative histopathology, respectively. US measurements were significantly smaller (p<0.001). The 71 breast carcinoma (CA) consisted of: invasive canalar (n=49), invasive lobular (n=11), in situ (n=3) and other types of CA (n=8). Twenty-nine patients had intraoperative re-excision (24 without residual CA), while 16 patients were re-operated due to insufficient histopathological RMs (12 without residual CA).Conclusion: Good correlation of minimal RMs between remote intraoperative US and postoperative histopathology warrants use of both techniques in a complementary manner. Remote intraoperative US is helpful in taking rapid decision of re-excision and maintaining low re-operation rate after breast-conserving surgery for non-palpable cancer.

Axillary Sentinel Lymph Node Biopsy for Breast Cancer and Melanoma Patients after Previous Axillary Surgery: A Systematic Review

Objective: Sentinel lymph node biopsy (SLNB) is a validated staging technique for breast carcinoma. Some women are exposed to have a second SLNB due to breast cancer recurrence or a second neoplasia (breast or other). Due to modi- fied anatomy, it has been claimed that previous axillary surgery represents a contra-indication to SLNB. Our objective was to analyse the literature to assess if a second SLNB is to be recommended or not. Methods: For the present study, we performed a review of all published data during the last 10 years on patients with previous axilla surgery and second SLNB. Results: Our analysis shows that second SLNB is feasible in 70%. Extra-axillary SNs rate (31%) was higher after radical lymph node dissection (ALND) (60% - 84%) than after SLNB alone (14% - 65%). Follow-up and com- plementary ALND following negative and positive second SLNB shows that it is a reliable procedure. Conclusion: The review of literature confirms that SLNB is feasible after previous axillary dissection. Triple technique for SN mapping is the best examination to highlight modified lymphatic anatomy and shows definitively where SLNB must be per- formed. Surgery may be more demanding as patients may have more frequently extra-axillary SN only, like internal mammary nodes. ALND can be avoided when second SLNB harvests negative SNs. These conclusions should however be taken with caution because of the heterogeneity of publications regarding SLNB and surgical technique.

Pour une chirurgie définitive d'emblée dans les ulcères gastro-duodénaux compliqués [Definitive surgery in complicated gastroduodenal ulcers].

Indications for surgical therapy in uncomplicated peptic ulcer disease have decreased considerably since the introduction of H2-receptor blocking drugs and more recently omeprazole. On the other side, the number of acute complications such as perforation or hemorrhage has remained nearly constant. The recent literature seems to indicate that the pattern of patients presenting with complications has changed and that the number of acute ulcers has increased. In a review of 283 patients, we found 150 perforated ulcers (PU) and 133 bleeding ulcers (BU). Almost all the patients with PU and 70% of the patients with BU have been treated operatively. The mortality is 14.3% and 12.5%, respectively. The vast majority of our patients have chronic ulcers, and only 7% have acute or subacute lesions confirmed by histologic examination. Based on our experience and the literature, we propose a therapeutic algorythm for these two conditions.

Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.

Chirurgie du diabète: provocation ou réalité [Surgery for diabetes: challenge or reality?]

Bariatric surgery techniques can usually increase either sensitivity or insulin resistance, acting on three different levels: decrease of food intake, malabsorption and modifications of entero-insulaire axis activity. This latter is taken into account in order to develop a new protocol to obtain diabetes remission without important weight loss and nutritional deficiencies. Preliminary results are interesting but they come from very short time studies with few patients. Moreover, complications rate is at present very high. Knowing better gastrointestinal mechanisms of diabetes control and especially incretins role is absolutely necessary before identifying surgery as a true metabolic treatment.

The 5th anniversary of "Patient Safety in Surgery" - from the Journal's origin to its future vision.

A prospective study was undertaken to determine prognostic markers for patients with obstructive jaundice. Along with routine liver function tests, antipyrine clearance was determined in 20 patients. Four patients died after basal investigations. Five patients underwent definitive surgery. The remaining 11 patients were subjected to percutaneous transhepatic biliary decompression. Four patients died during the drainage period, while surgery was carried out for seven patients within 1-3 weeks of drainage. Of 20 patients, only six patients survived. Basal liver function tests were comparable in survivors and nonsurvivors. Discriminant analysis of the basal data revealed that plasma bilirubin, proteins and antipyrine half-life taken together had a strong association with mortality. A mathematical equation was derived using these variables and a score was computed for each patient. It was observed that a score value greater than or equal to 0.84 indicated survival. Omission of antipyrine half-life from the data, however, resulted in prediction of false security in 55% of patients. This study highlights the importance of addition of antipyrine elimination test to the routine liver function tests for precise identification of high risk patients.

Free conjunctival autologous graft for bleb repair and bleb reduction after trabeculectomy and nonpenetrating filtering surgery.

PURPOSE: To describe methods and outcomes of excisional revision of a filtering bleb (bleb revision) using free conjunctival autologous graft either for bleb repair or for bleb reduction after trabeculectomy and deep sclerectomy with an implant. METHODS: Retrospective medical records were reviewed for a consecutive non-comparative case series comprising patients who underwent excisional revision of a filtering bleb between May 1998-January 2001. Excisional revision using free conjunctival autologous graft (bleb revision) was performed either for bleb repair, to treat early and late leaks and hypotony with maculopathy, or for bleb reduction, to improve ocular pain, discomfort, burning, foreign body sensation, tearing, and fluctuations of visual acuity. The revision consisted of bleb excision and free conjunctival autologous graft. The bleb histopathology was analyzed in patients who underwent bleb repair. RESULTS: Sixteen patients were included in the study, consisting of nine patients who had a trabeculectomy and seven patients who had a deep sclerectomy with an implant. Bleb revision was necessary in 14 patients due to leaking filtering bleb (bleb repair), and in 2 patients due to bleb dysesthesia (bleb reduction). After a follow-up of 15.1 +/- 8.4 months, the mean intraocular pressure (IOP) rose from 7.8 +/- 6.3 mm Hg to 14.3 +/- 6.5 mm Hg, and the visual acuity from 0.4 +/- 0.3 to 0.7 +/- 0.3, with a P value of 0.008 and 0.03, respectively. The complete success rate at 32 months, according to the Kaplan-Meier survival curve, was 38.3%, and the qualified success rate was 83.3%. Four patients (25%) required additional suturing for persistent bleb leak. To control IOP, antiglaucoma medical therapy was needed for six patients (37.5%) and repeated glaucoma surgery was needed for one patient. CONCLUSION: Free conjunctival autologous graft is a safe and successful procedure for bleb repair and bleb reduction. However, patients should be aware of the postoperative possibility of requiring medical or surgical intervention for IOP control after revision.

Quoi de neuf en chirurgie [Novelties in surgery in 2013?].

Multidisciplinary management of colorectal liver metastases allows an increase of about 20% in the resection rate of liver metastases. It includes chemotherapy, interventional radiology and surgery. In 2013, the preliminary results of the in-situ split of the liver associated with portal vein ligation (ALLPS) are promising with unprecedented mean hypertrophy up to 70% at day 9. However, the related morbidity of this procedure is about 40% and hence should be performed in the setting of study protocol only. For pancreatic cancer, the future belongs to the use of adjuvant and neo adjuvant therapies in order to increase the resection rate. Laparoscopic and robot-assisted surgery is still in evolution with significant benefits in the reduction of cost, hospital stay, and postoperative morbidity. Finally, enhanced recovery pathways (ERAS) have been validated for colorectal surgery and are currently assessed in other fields of surgery like HPB and upper GI surgery.

Stress ulcer prophylaxis in non-critically ill patients: a prospective evaluation of current practice in a general surgery department

Objective: There is little evidence regarding the benefit of stress ulcer prophylaxis (SUP) outside critical care setting. Over-prescription of SUP is not devoid of risks. This prospective study aimed to evaluate the use of proton pump inhibitors (PPIs) for SUP in a general surgery department.Methods: Data collection was performed prospectively during an 8-week period on patients hospitalized in a general surgery department (58 beds) by pharmacists. Patients with a PPI prescription for the treatment of ulcers, gastro-oesophageal reflux disease, oesophagitis or epigastric pain were excluded. Patients admitted twice during the study period were not re-included. The American Society of Health-System Pharmacists guidelines on SUP were used to assess the appropriateness of de novo PPI prescriptions.Results: Among 255 consecutive patients in the study, 138 (54%) received a prophylaxis with PPI, of which 86 (62%) were de novo PPI prescriptions. One-hundred twenty-nine patients (94%) received esomeprazole (according to the hospital drug policy). The most frequent dosage was 40 mg/day. Use of PPI for SUP was evaluated in 67 patients. Fifty-three patients (79%) had no risk factors for SUP. Twelve and 2 patients had one or two risk factors, respectively. At discharge, PPI prophylaxis was continued in 34% of patients with a de novo PPI prescription.Conclusion: This study highlights the overuse of PPIs in non-ICU patients and the inappropriate continuation of PPI prescriptions at discharge.Treatment

Chirurgie viscérate chez le patient greffé ou en attente d'une transplantation [Visceral surgery in organ transplant recipients or in patients awaiting transplantation]

Patients receiving immunosuppression are at higher risk for gastrointestinal complications: mortality is high if they are not diagnosed and treated rapidly. Systematic screening for cholelithiasis or diverticular disease, and prophylactic surgery, are not recommended systematically anymore. Patients awaiting a transplant with abdominal symptoms should be investigated without delay and surgery, if indicated and whenever possible based on the anaesthetic evaluation, should be performed. In the transplant population, a high degree of suspicion must be raised in case of any abdominal symptom. Radiological investigations and surgery without delay are often the only ways to preserve the function of the graft and optimize the patient's survival.

Resuming motor vehicle driving following orthopaedic surgery or limb trauma.

Following elective orthopaedic surgery or the treatment of a fracture, patients are temporarily unable to drive. This loss of independence may have serious social and economic consequences for the patient. It is therefore essential to know when it is safe to permit such patients to return to driving. This article, based upon a review of the current literature, proposes recommendations of the time period after which patients may safely return to driving. Practical decisions are made based upon the type of surgical intervention or fracture. Swiss legislation is equally approached so as to better define the decision.