Benefits of a standardized protocol for axillary management after neoadjuvant chemotherapy in a single center

Introduction: The axillary lymph node status is one of the most important prognostic factors in breast cancer. For locally advanced tumors, neoadjuvant chemotherapy favors higher rates of breast lumpectomy and downstaging tumor burden of axilla. The aim of this study was to evaluate the use of a standardized image-guided protocol after neoadjuvant chemotherapy to enable sentinel node dissection in patients with axillary downstaging, avoiding axillary dissection. Methods: Retrospective cohort study of data collected from medical records of patients who underwent neoadjuvant chemotherapy in a single center, from January 2014 to December 2018. The protocol comprises the placement of a metal clip in positive axillary lymph node, in patients with up to two clinically abnormal lymph nodes presented on imaging. After neoadjuvant chemotherapy, and once a radiologic complete response was achieved, sentinel node dissection was performed using blue dye and radiotracer. Axillary dissection were avoided in patients whose clipped sentinel node were negative for metastasis and in patients with three identified and negative sentinel node dissection. Results: A total of 471 patients were analyzed for this study: 303 before and 165 after the implementation of the protocol; 3 cases were excluded. The rate of sentinel node dissection in clinical nodes positive patients was statistically higher in this group when compared to patients treated before the protocol implementation (22.8% vs. 40.8%; p=0.001). Patients with triple negative and HER2-positive tumors underwent sentinel node dissection more frequently when compared to luminal tumors (p=0.03). After multivariate analysis, the variables that were associated with a greater chance of performing sentinel node dissection were clinical staging, type of surgery performed and implementation of the axillary assessment protocol. Conclusions: The results showed that the use of an easily and accessible image-guided protocol can improve sentinel node dissection in selected patients, even if the lymph node was positive previously to neoadjuvant treatment.

Diaphanization: a standardized protocol for non-fetal tissue preservation / Diafanización: un protocolo estandarizado para la preservación de tejido adulto

In response to the arising difficulty of dissection use during anatomy courses, medical schools have been forced to research alternative teaching methods. These are meant to help students develop three dimensional mental images of the human body and increase spatial reasoning, thus improving the learning process of human morphology. One of those methods, used at the Universidad de los Andes is the Diaphanization process. This technique is a well-known method for specimen preservation, used as an anatomy research and teaching tool. Even though it is frequently used, finding a standardized protocol in indexed journals is not possible, which hinders the use of the technique. The standardization of an updated protocol is a need in order to continue exploiting the maximum educational capacity of the specimens used during classwork. The process used at the Universidad de los Andes for non-fetal tissue preservation by Diaphanization is described, with a detailed explanation of its five main stages: Injection, Fixation, Dehydration, Bleaching (or Maceration) and Final preservation. The final result should be an organ preserved in an acrylic box which allows clear three dimensional visualization of anatomical structures that can be used for the study and description of general anatomy and vascular structure. It also helps with spatial reasoning and represents little to no biological risk, leading to a new level of anatomical teaching and experimenting. Several specimens obtained at our laboratory through this technique are presented.

Como respuesta a la dificultad del uso de disección como una herramienta en el curso de anatomía, las escuelas de medicina se han visto forzadas a investigar y desarrollar métodos alternativos que la reemplacen. Estos pretenden estimular el desarrollo de la percepción tridimensional de los estudiantes, logrando mejor racionamiento espacial, y así, mejorando el proceso de aprendizaje de la morfología humana. Uno de estos métodos, en uso en la Universidad de los Andes, es el proceso de diafanización. Esta técnica es ampliamente conocida en el ámbito de preservación de tejidos, y empleada en investigación y educación. Aún con su uso frecuente, un protocolo estandarizado que la describa no está disponible en la literatura indexada, lo cual limita su uso. La estandarización de un protocolo actualizado es necesaria para permitir el continuo uso de esta técnica. Se describe el proceso de preservación de tejido adulto mediante la diafanización, con una explicación detallada de los 5 pasos que la componen: Inyección, Fijación, Deshidratación, Macerado y Preservación final. El resultado es un órgano inmerso en glicerina en un contenedor de acrílico que permite una visualización tridimensional de las estructuras anatómicas del espécimen, que puede ser empleado por los estudiantes para su estudio, y permite una descripción de la anatomía general del modelo y su estructura vascular. Adicionalmente incrementa el razonamiento espacial de los estudiantes, y no presenta ningún riesgo biológico. Se presentan una variedad de especímenes de características particulares obtenidos mediante la aplicación de esta técnica.

The Current Status of Enteral Feeding Management in General Surgical Ward

PURPOSE: Development of a standardized guideline and assessment tool is necessary. Therefore, the aim is to investigate the current state of enteral feeding management and to develop a basis for a standardized guideline. METHODS: From July 1, 2010 through June 30, 2011, this study was conducted retrospectively for 100 patients who had enteral feeding more than once only in the Intensive Care Unit, after General Surgery at Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. The analysis was based on the following factors; age, diagnosis, name of the operation, period of start and the end of enteral feeding, method of injection, flushing method, residual volumes of the stomach, location and the size of the tube, medication through tubing, and complications related to enteral feeding. RESULTS: The mean age of the patients was 60.5, 65 men and 35 women. There were 30 malignant tumors of the hepatobiliary system and pancreas, 8 gastric and duodenal cancer, 4 colon and rectal cancer, 11 peritonitis, hemoperitoneum, and bowel obstruction, and 47 others. The average period of performing enteral feeding was 11.7 days and the locations of enteral feeding tube were stomach 56%, jejunum 39%, duodenum 3%, and undescribed 2%. The methods of enteral feeding were as follows; continuous feeding 19%, cyclic feeding 75%, intermittent and bolus feeding 3%, respectively. Only 1% of patients were on flushing and 16% on stomach residual. The most common complication of enteral feeding was clogging of the tube (5%). CONCLUSION: Due to the lack of detailed charting related to enteral feeding, we were unable to analyze the statistics on the relevance of complication which was the primary endpoint. As a result, development of a standardized protocol on charting enteral feeding is suggested for optimal enteral nutritional support.