Volume of breast tissue excised during breast-conserving surgery in patients undergoing preoperative systemic therapy

PURPOSE: We aimed to determine whether clinical examination could adequately ascertain the volume of tissue to be resected during breast-conserving surgery after neoadjuvant therapy. METHODS: We reviewed the clinical reports of 279 patients with histologically diagnosed invasive breast carcinomas treated with neoadjuvant therapy followed by surgery or with primary surgery alone. We estimated volumes of excised tissues, the volume of the tumor mass and the optimal volume required for excision based on 1 cm of clear margins. The actual excess of resected volume was estimated by calculating the resection ratio measured as the volume of the resected specimen divided by the optimal specimen volume. The study endpoints were to analyze the extent of tissue resection and to ascertain the effect of excess resected tissue on surgical margins in both groups of patients. RESULTS: The median tumor diameter was 2.0 and 1.5 cm in the surgery and neoadjuvant therapy groups, respectively. The median volume of resected mammary tissue was 64.3 cm³ in the primary surgery group and 90.7 cm³ in the neoadjuvant therapy group. The median resection ratios in the primary surgery and neoadjuvant therapy groups were 2.0 and 3.3, respectively (p<0.0001). Surgical margin data were similar in both groups. Comparison of the volume of resected mammary tissues with the tumor diameters showed a positive correlation in the primary surgery group and no correlation in the neoadjuvant therapy group. CONCLUSION: Surgeons tend to excise large volumes of tissue during breast-conserving surgery after neoadjuvant therapy, thereby resulting in a loss of the correlation between tumor diameter and volume of the excised specimen.

Oral triiodothyronine for the prevention of thyroid hormone reduction in adult valvular cardiac surgery

Treatment of non-thyroidal illness by intravenous triiodothyronine (T3) after cardiac surgery causes a disproportional elevation of hormone levels. The administration of oral T3, which has never been studied in this context, could cause physiological hormone levels. The aim of this study was to test oral T3 for the prevention of T3 reduction during the postoperative period of valvular cardiac surgery in adults. Eighteen patients who underwent cardiac surgery for valvular disease with invasive hemodynamic monitoring were randomly assigned to 2 groups: the T group received oral T3 (N = 8), 25 µg three times/day, initiated 24 h before surgery and maintained for 48 h and the NT group (N = 10) received placebo. Serum T3, thyroxine and thyrotropin were determined at baseline, 1 h before surgery, within 30 min of cardiopulmonary bypass and 6, 12, 24, and 48 h after removal of the aortic cross-clamp. Baseline T3 was similar in both groups (T: 119 ± 13; NT: 131 ± 9 ng/dL). Serum T3 increased during the first 24 h in the T group compared to the NT group (232 ± 18 vs 151 ± 13 ng/dL; P < 0.001). In the NT group, T3 was reduced by 24% (P = 0.007) 6 h after removal of the aortic cross-clamp, confirming the non-thyroidal illness syndrome. There were no differences in clinical or hemodynamic parameters between groups. Administration of oral T3 prevented its serum reduction after valvular cardiac surgery in adults, with normal serum levels for 48 h without disproportional elevations.

Reliability of toluidine blue application in the detection of oral epithelial dysplasia and in situ and invasive squamous cell carcinomas

Objective, the objective of this study was to evaluate the reliability of in vivo staining with toluidine blue in the detection of oral epithelial dysplasia, in situ carcinoma, and invasive squamous cell carcinomas in potentially malignant epithelial lesions (PMELs) and superficial oral ulcerations suggesting malignancy.Study design. Fifty patients with PMELs and superficial oral ulcerations suggestive of malignancy were selected from those treated at the Oral Medicine Service, Faculty of Dentistry, Araraquara, Brazil. All lesions were submitted to staining with an aqueous solution of 1% toluidine blue, followed by biopsy and histologic analysis. The sensitivity, specificity, and positive and negative predictive values were calculated.Results. Histologic diagnosis revealed that 14% of the lesions analyzed were in situ carcinoma and invasive squamous cell carcinomas, 12% were epithelial dysplasias, 13% were keratosis, 40% were lichen planus, and 8% were other benign lesions. The sensitivity uf the staining was 77%, the specificity 67%, and the positive and negative predictive values 43.5% and 88.9%, respectivelyConclusions, Staining with toluidine blue was demonstrated to be highly reliable in the detection of in situ carcinoma acid invasive squamous cell carcinoma, because false-negative results for the lesions did not occur. Toluidine blue staining is an adjunct to clinical judgment and not a substitute for either judgment or biopsy.

Microleakage evaluation of pit and fissure sealants done with different procedures, materials, and laser after invasive technique

This study evaluated the microleakage of pit and fissure sealants after different surface preparation (invasive technique and laser irradiation) and the use of different materials (fluoride resin-filled sealant, resin-modified glass ionomer cement and adhesive system). Eighty-four pre molars were used in this study, which were divided into seven groups. After the accomplishment of the different treatments, these were submitted to thermocycling process and assess for microleakage by examination under an epifluorescent microscope and scored zero to seven. Two specimens of each group were observed under scanning electron microscope (SEM). The results showed that laser irradiation did not lessen microleakage in pit and fissures when using a filled-resin sealant with fluoride or a resin-modified glass ionomer cement. The use of laser irradiation and adhesive system, followed by a resin-filled sealant with fluoride, showed the lowest microleakage scores in pit and fissures. Comparing this group to the resin-modified glass ionomer cement group, there was statistical significance. The use of a adhesive system decreased microleakage when using a fluoride resin-filled sealant with or without previous laser irradiation; although it was not statistically significant.

Invasive enteritis by Strongyloides stercoralis presenting as acute abdominal distress under corticosteroid therapy.

Overwhelming helminthiasis is still a problem in endemic areas, especially in immunocompromised patients. We report a case of invasive intestinal strongyloidiasis that was clinically expressed as acute abdominal distress in a 73-year-old man from São Paulo who had been receiving methylprednisone, 20 mg/day, for one year for osteoarthritis. A surgical specimen from the ileum revealed invasive enteritis with severe infestation by Strongyloides stercoralis. The patient died of sepsis 6 days after surgery. The possibility of invasive strongyloidiasis should be considered in the differential diagnosis of acute abdominal distress in patients undergoing immunosuppressive therapy.

Periodontal plastic surgery associated with treatment for the removal of gingival overgrowth

Background: Excisional biopsies of gingival overgrowths, performed with safety margins, frequently result in mucogingival defects. These defects may produce esthetic problems and increase the chances of dentin hyperesthesia and its possibility of hindering oral hygiene. Methods: Two clinical cases are reported in which gingival overgrowths were removed by excisional biopsy, resulting in unsightly defects. The first clinical case presents an invasive approach for the treatment of a recurrent pyogenic granuloma in the anterior maxilla, and the second depicts a complete removal of a peripheral odontogenic fibroma in the posterior maxilla. In both situations, the soft-tissue defects were repaired by periodontal plastic surgery, including a laterally positioned flap and a coronally positioned flap, respectively. Results: Periodontal plastic surgery successfully restored the defects that resulted from biopsies, and no recurrence has been noticed in the 5-year postoperative follow-up period. Conclusions: The combination of biopsy and periodontal plastic surgery in a one-step procedure seems to be suitable to remove gingival overgrowths in most areas of the mouth, regardless of esthetic significance. Such procedures seem to restore gingival health, encourage healing, and create both esthetics and function in the excised area.

Treatments for invasive carcinoma of the cervix: What are their impacts on the pelvic floor functions?

Aims: Describe the impact of surgery, radiotherapy and chemoradiation in the pelvic floor functions in cervical cancer patients. Materials and Methods: A prospective study with women submitted to radical hysterectomy (RH) (n = 20),exclusive radiotherapy (RT) (n= 20)or chemoradiation (CT/RT)(n = 20)for invasive cervical cancer. Urinary, intestinal and sexual function, as well as vaginal length and pelvic floor musclecontraction were evaluated. Comparisons between groups were performed by Kruskal-Wallis and Chi-square tests (p < 0.05). Results: The groups were similar in stress urinary incontinence incidence (p = 0.56), urinary urgency (p = 0.44),urge incontinence (p = 0.54),nocturia(p = 0.53), incomplete bowel emptying (p = 0.76),bowel urgency(p = 0.12)and soilage(p = 0.43). The CT/ RT group presented a higher urinary frequency(p < 0.001)and diarrhea(p = 0.025). Patients in the RH group were more sexually active(p = 0.01) and experienced less dyspareunia (p = 0.021). Vaginal length was shorter in RT group (5.5 ± 1.9 cm) and CT/ RT(.3 ± 1.5 cm) than in the RH group (7.4 ± 1.1 cm) (p < 0.001). Pelvic floor muscle contraction was similar (p = 0.302). Conclusions: RT and CT/RT treatment for cervical carcinoma are more associated to sexual and intestinal dysfunctions.

Peritoneal response to abdominal surgery: the role of equine abdominal adhesions and current prophylactic strategies

Intra-abdominal adhesions constitute a significant clinical and surgical problem that can lead to complications such as pain and bowel occlusion or subocclusion. These adhesions are frustrating and potentially fatal, representing a major postoperative complication in abdominal surgery. It is estimated that 32% of horses undergoing laparotomy will present clinical symptoms due to adhesions, but the true prevalence is not known because a large proportion of animals with postoperative recurrent colics are medically treated or submitted to euthanasia without necropsy. Adhesions are highly cellular, vascularized, dynamic structures that are influenced by complex signaling mechanisms. Understanding their pathogenesis could assist in applying better therapeutic strategies and in developing more effective antiadhesion products. Currently, there are no definitive strategies that prevent adhesion formation, and it is difficult to interpret the results of existing studies due to nonstandardization of an induction model and evaluation of their severity. The best clinical results have been obtained from using minimally traumatic surgical techniques, anti-inflammatory agents, antimicrobials, anticoagulants, and mechanical separation of serosal surfaces by viscous intraperitoneal solutions or physical barriers. This paper aims to review adhesion formation pathogenesis, guide the understanding of major products and drugs used to inhibit adhesion formation, and address their effectiveness in the equine species.

Non invasive assessment of right ventricle in patients with operated tetralogy of Fallot

The objective of this study was to evaluate right ventricular function in patients with right ventricular volume overload in patients with (tetralogy of Fallot, and pulmonary atresia + VSD ) underwent corrective surgery; with echocardiography measure that can be easily applied; and to study the relationship between ProBNP and the contractile function of the right ventricle, dilated right atrium, and the consequences of pulmonary insufficiency . Methods: The study included 50 patients (50% males, mean age 30.64 ± 13.30 years) with prior cardiac surgical intervention of TDF (90%) or pulmonary atresia + VSD (10%). (49 pz) have performed a cardiac MRI and clinical evaluation, (47 pz) echocardiogram, (48 pz) ECG, (34 pz) a cardiopulmonary exercise testing, (29 pz) a dosage of ProBNP. Results: The S-wave velocity (p <0.0001), the TAPSE (p <0.0001) correlated significantly with RVEF estimated by cardiac MRI. The VO2 max was 27.93 ± 12.91 ml / kg / min, 15% of patients had VE/VCO2 The peak> 35. ProBNP correlated positively and significantly with the area of the right atrium (p = 0.0001), and negative and significant with VO2 max (p = 0.04). Those who have increased pulmonary insufficiency (PVR fraction> 30%) have a significantly increased RVED volume (p = 0.01), reduced VO2 max (p = 0.04), and lower ejection fraction of LV (p = 0.02) than the group of patients with PVR ≤ 30. Conclusion: The TAPSE and S-wave velocity are fundamental and may become the technique of choice for routine assessment of RV systolic function in adult patients with TOF. The monitoring of the Pro BNP is probably a choice, given the simplicity and their information that correlate with the test cardiopulmonary. In view of the ventricular-ventricular interaction, so measures to maintain or restore the functioning of the pulmonary valve could preserve biventricular function.

New Application of Piezoelectric Ultrasounds in Maxillo-facial bone surgery

Background: Piezoelectric instrumentation seems to offer 3 important advantages for cutting bone structures. Be more precise because it is produced by micro-vibrations from the cutting insert. Be safer because the ultrasonic frequency used does not affect soft tissue. Thirdly, the less invasive cutting action produces minor tissue damage and consequently probably a better healing Aim of the Study: The aim of this study is to evaluate the effectiveness of piezoelectric device capability in maxillo-facial surgery, in order to take advantage of these favourable capacity. Material and Methods: Considering the several potential application of the piezoelectric technology in Orthognathic, Oncologic and Extractive surgery, we would like to design protocols in order to verify how this new device can modify the surgical technique, the surgical time, the patients healing and its quality of life. Results: Due to the precise Piezosurgery cut, we can manage the Cad-Cam-Custom Made plates protocol in Oncologic Surgery and in Orthognatic Surgery increasing our percentage of comparison between the 3D preoperative plan and the surgical execution. We also found a better quality of life impaction in Patient who underwent and extractive surgery Conclusion: Piezosurgery device seems to be a strong surgical aid were safe and precise cut are needed and its capability to reduce the discomfort Patients need to be study in deep also in major surgery like Orthognatic and Oncologic surgery.

No difference in anterior tibial translation with and without posterior cruciate ligament in less invasive total knee replacement

The relative advantages of cruciate retaining or cruciate resecting total knee replacement are still controversial. If the posterior cruciate ligament (PCL) is preserved, it should be properly balanced. In a previous study, it was demonstrated that increasing the flexion gap leads to an anterior translation of the tibia relative to the femur. Based on these results, we hypothesized that cutting the PCL increases the flexion gap and lessens anterior tibial translation.

The Shelhigh No-React bovine internal mammary artery: a questionable alternative conduit in coronary bypass surgery?

BACKGROUND: Increasing age and comorbidities among patients undergoing coronary artery bypass surgery (CABG) stimulates the exhaustive research for alternative grafts. No-React treatment should render the tissue resistant against degeneration and reduce early inflammatory response. The aim of the present study was an invasive assessment of the patency of No-React bovine internal mammary artery (NRIMA grafts) used as bypass conduit in CABG surgery. PATIENTS AND METHODS: Nineteen NRIMA grafts were used in 17 patients (2.9%) out of a total of 572 patients undergoing CABG surgery within a 12-month period. All intraoperative data were assessed and in-hospital outcome was analysed. Follow-up examination was performed 7.0+/-4.0 months after initial surgery, including clinical status and coronary angiography to assess patency of the NRIMA grafts. RESULTS: Average perioperative flow of all NRIMA grafts was 71+/-60 ml/min. One patient died in hospital due to a multi-organ failure. Four patients refused invasive assessment. Follow-up was complete in 12 patients with overall 13 NRIMA grafts. Nine NRIMA grafts (69.2%) were used for the right coronary system, two NRIMA grafts (15.4%) on the LAD and two on the circumflex artery. Graft patency was 23.1% and was independent of the intraoperative flow measurement. CONCLUSIONS: NRIMA grafts show a very low patency and cannot be recommended as coronary bypass graft conduits. Patency was independent of the perioperative flow, assessed by Doppler ultrasound. Because of this unsatisfying observation, this type of graft should be utilised as a last resource conduit and used only to revascularise less important target vessels, such as the end branches of the right coronary artery.

Surgery-related risk factors

PURPOSE OF REVIEW: The surgical procedure remains the key element in the multidisciplinary treatment of a wide variety of degenerative, traumatic, tumorous, congenital, and vascular diseases, resulting in an estimated 234 million surgical interventions worldwide each year. Undesired effects are inherent in any medical intervention, but are of particular interest in an invasive procedure for both the patient and the responsible physician. Major topics in current complication research include perception of key factors responsible for complication development, prediction, and whenever possible, prevention of complications. RECENT FINDINGS: For many years, the technical aspects of surgery and the skills of the surgeon her/himself were evaluated and considered as the main sources of surgical complications. However, recent studies identified many nontechnical perspectives, which could improve the overall quality of surgical interventions. SUMMARY: This article reviews selected, recently published data in this field and aims to point out the complexity and multidimensional facets of surgery-related risk factors.

Minimal-invasive percutaneous reduction and transsacral screw fixation for U-shaped fractures

STUDY DESIGN Technical note and case series. OBJECTIVE To introduce an innovative minimal-invasive surgical procedure reducing surgery time and blood loss in management of U-shaped sacrum fractures. SUMMARY OF BACKGROUND Despite their seldom appearance, U-shaped fractures can cause severe neurological deficits and surgical management difficulties. According to the nature of the injury normally occurring in multi-injured patients after a fall from height, a jump, or road traffic accident, U-shaped fractures create a spinopelvic dissociation and hence are highly unstable. In the past, time-consuming open procedures like large posterior constructs or shortening osteotomies with or without decompression were the method of choice, sacrificing spinal mobility. Insufficient restoration of sacrococcygeal angle and pelvic incidence with conventional techniques may have adverse long-term effects in these patients. METHODS In a consecutive series of 3 patients, percutaneous reduction of the fracture with Schanz pins inserted in either the pedicles of L5 or the S1 body and the posterior superior iliac crest was achieved. The Schanz pins act as lever, allowing a good manipulation of the fracture. The reduction is secured by a temporary external fixator to permit optimal restoration of pelvic incidence and sacral kyphosis. Insertion of 2 transsacral screws allow fixation of the restored spinopelvic alignment. RESULTS Anatomic alignment of the sacrum was possible in each case. Surgery time ranged from 90 to 155 minutes and the blood loss was <50 mL in all 3 cases. Two patients had very good results in the long term regarding maintenance of pelvic incidence and sacrococcygeal angle. One patient with previous cauda equina decompression had loss of correction after 6 months. CONCLUSIONS Percutaneous reduction and transsacral screw fixation offers a less invasive method for treating U-shaped fractures. This can be advantageous in treatment of patients with multiple injuries.

Pelvic tilt is minimally changed by total hip arthroplasty

BACKGROUND While surgical navigation offers the opportunity to accurately place an acetabular component, questions remain as to the best goal for acetabular component positioning in individual patients. Overall functional orientation of the pelvis after surgery is one of the most important variables for the surgeon to consider when determining the proper goal for acetabular component orientation. QUESTIONS/PURPOSES We measured the variation in pelvic tilt in 30 patients before THA and the effect of THA on pelvic tilt in the same patients more than a year after THA. METHODS Each patient had a CT study for CT-based surgical navigation and standing and supine radiographs before and after surgery. Pelvic tilt was calculated for each of the radiographs using a novel and validated two-dimensional/three-dimensional matching technique. RESULTS Mean supine pelvic tilt changed less than 2°, from 4.4° ± 6.4° (range, -7.7° to 20.8°) before THA to 6.3° ± 6.6° (range, -5.7° to 19.6°) after THA. Mean standing pelvic tilt changed less than 1°, from 1.5° ± 7.2° (range, -13.1° to 12.8°) before THA to 2.0° ± 8.3° (range, -12.3° to 16.8°) after THA. Preoperative pelvic tilt correlated with postoperative tilt in both the supine (r(2) = 0.75) and standing (r(2) = 0.87) positions. CONCLUSIONS In this population, pelvic tilt had a small and predictable change after surgery. However, intersubject variability of pelvic tilt was high, suggesting preoperative pelvic tilt should be considered when determining desired acetabular component positioning on a patient-specific basis.