Comparison of resection margins and cosmetic outcome following intraoperative ultrasound-guided excision versus conventional palpation-guided breast conservation surgery in breast cancer: A randomized controlled trial

INTRODUCTION: Use of intraoperative ultrasound (IOUS) has been shown to help achieve satisfactory cosmesis and negative margins in breast conserving surgery (BCS). This study has been done to compare the oncological and cosmetic outcomes following BCS using conventional palpatory method and IOUS. MATERIALS AND METHODS: This is a prospective randomized controlled trial conducted at a tertiary care teaching and research institute in India. Patients with early operable breast cancer willing for BCS were included. Tumors were excised with 1 cm margin. In palpatory group, tumor was palpated and 1 cm margin was taken with a measuring scale while in the second group, IOUS was used to mark the margins. Histopathological evaluation was done to assess margins and cosmesis was assessed by patient, resident doctor, and nurse independently. RESULTS: Sixty patients were included, 32 in the ultrasonography-guided and 28 in palpation-guided wide local excision. The mean age of patients was 48.78 years. In both groups, mean tumor size was 3.18 cm. Margin thickness and positivity was higher in palpatory group (though P > 0.05). Most patients were satisfied with cosmesis. There was no significant difference in complications and specimen volume in both groups. Presence of ductal carcinoma in situ component and expression of Her2neu by tumor cells had a significant impact on margin positivity. CONCLUSIONS: Intraoperative use of ultrasound offers a real-time assessment of margin status and may reduce the margin positivity rate compared to conventional palpation-guided method.

Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: A prospective cohort study.

BACKGROUND: The aim of this study was to assess the cosmetic outcome of patients undergoing oncoplastic breast conserving surgery in Indian population. MATERIALS AND METHODS: A prospective cohort of 35 patients who were eligible for breast conservation surgery was included in the study from year 2007 to 2009. Patients with central quadrant tumors were excluded from the study. A double ‑ blind cosmetic assessment was done by a plastic surgeon and a senior nurse not involved in the management of patients. Moreover, self‑assessment was carried out by the patient regarding the satisfaction of surgery, comfort with brasserie, social and sexual life after oncoplastic surgery. RESULTS: In this study, 35 patients underwent oncoplastic breast conservation surgery by various techniques. The cosmetic outcome scores of the surgeon and nurse were analyzed for inter rater agreement using inter‑class Correlation Coefficients. There was a good association between them. The risk factors for poor cosmetic outcome was studied by univariate analysis and significant correlation was obtained with age, volume of breast tissue excised and estimated percentage of breast volume excised (P < 0.05). Moreover, 96% of patients were moderately to extremely satisfied with the surgery. Patients were offered an option for cosmetic correction of contralateral breast by mastopexy or reduction mammoplasty however, none of them agreed for another procedure. CONCLUSIONS: Oncoplastic breast surgery helps to resect larger volume of tissue with wider margins around the tumor. It helps to achieve better cosmesis and extends the indications for breast conservation. Most of the patients were satisfied with mere preservation of the breast mound rather than a symmetrical contralateral breast.

Leiomyosarcoma of inferior vena cava: A case series of four cases.

Vascular leiomyosarcomas are rare tumors, arising most frequently from inferior vena cava (IVC). They are mostly seen in sixth decade, with a female predominance. Their diagnosis is often challenging, as patients may present with non-specific complaints such as dyspnea, malaise, weight loss, abdominal pain, or back pain, preceding the diagnosis by several years. Leiomyosarcoma of the IVC most frequently occurs in the middle segment. The final diagnosis can be made by an ultrasound or computed tomography guided biopsy. Because of limited experience with this disease, optimal management of IVC leiomyosarcoma is unknown. Curative surgical resection remains the current treatment of choice for primary leiomyosarcoma of IVC. Neoadjuvant therapy may be given to downsize the tumor and increase resectability rates. Nonetheless, when complete resection is not possible, debulking combined with radiation therapy still provides good palliation. We, hereby, report four cases of this rare entity with emphasis on management.

Role of axillary sampling in the era of sentinel lymph node biopsy: A critical review.

Axillary lymph node dissection is the standard of care for treating and staging axilla in breast cancer. Sentinel lymph node biopsy and axillary sampling have been advocated as an alternative to axillary lymph node dissection with an added benefit of lesser morbidity. Herein, we are reviewing the role of axillary sampling in the present era of sentinel lymph node biopsy in the background of standard axillary dissection.

Second echelon node predicts metastatic involvement of additional axillary nodes following sentinel node biopsy in early breast cancer.

BACKGROUND: In many patients with early breast cancer, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients may not benefit from completion axillary lymph node dissection (CALND). AIMS: This pilot study evaluates the status of 2nd echelon (station) lymph nodes in the axilla as a predictor of additional positive nodes in the axilla in the presence of sentinel node metastasis. SETTINGS AND DESIGN: Cross-sectional study of 40 breast cancer patients. MATERIALS AND METHODS: Forty patients with invasive breast cancer underwent SLN biopsy followed by 2nd echelon lymph node biopsy in the same sitting. SLN mapping was performed using a combined technique of isosulfan blue and 99 mTc-sulfur colloid. SLNs (Station I) were defined as blue and/or hot nodes. These nodes were then injected with 0.1 ml of blue dye using a fine needle and their efferent lymphatic was traced to identify the Station II nodes. Then a complete ALND was performed. All the specimens were sent separately for histopathological evaluation. RESULTS: SLNs (Station I nodes) were successfully identified in 98% (39/40) patients. Of the 17 patients with a positive SLN, 8 (47%) patients had no further positive nodes in the axilla, 9 (53%) patients had additional metastasis in nonsentinel lymph nodes upon CALND. Station II nodes were identified in 76% (13/17) patients with a positive SLN. Station II nodes accurately predicted the status of the remaining axilla in 92% patients (12/13). STATISTICAL ANALYSIS: We calculated the Sensitivity, Negative predictive value, Positive predictive value, False negative rate and Identification rate. CONCLUSION: Station II nodes may predict metastatic involvement of additional nodes in the axilla.

Hepatic hydatid cysts with biliary, and peritoneal rupture and transdiaphragmatic migration.

Hydatid disease is a parasitic infection that most commonly involves the liver. Imaging plays a vital role in the diagnosis of this disease. Rupture of the cyst can give rise to a wide spectrum of complications. We describe a case of hepatic hydatid cyst with rupture into the biliary tree, right pleural cavity and dissemination into the peritoneal cavity, with associated splenic hydatid cysts. MRI may be a useful non-invasive diagnostic tool in such disseminated cases to define the complete extent of the disease.

Spontaneous appendico-cutaneous fistula--a rare complication of acute appendicitis.

Spontaneous Appendicocutaneous fistula (SACF) is a rare complication of acute perforating appendicitis. We describe one such case where the patient presented with a chronic discharging sinus in the right flank. Pathogenesis of this unusual lesion, its clinical presentation and the management are discussed and the literature reviewed. Preoperative diagnosis of this condition needs high index of suspicion. CT fistulogram is a valuable aid in this regard.

Factors influencing wound infection following laparoscopic cholecystectomy.

Although risk factors for wound infection following conventional open cholecystectomy have been extensively studied in the literature, for laparoscopic cholecystectomy (LC) these have not been evaluated thoroughly. We studied factors that influence wound infection following LC. The aim of our study was to evaluate the incidence of wound infection following LC in low-risk patients and the factors that influence its causation. Over a 2-year period, 113 low-risk patients undergoing elective LC for symptomatic gall stone disease were included in this study. Nasal swab and abdominal skin swab cultures were taken one day prior to surgery to detect any aerobic organisms. Intraoperatively, gallbladder bile and a swab from the epigastric port were taken for aerobic and anaerobic culture. Post-operatively, a wound swab was taken from the infected port site (if any) and cultured to detect any aerobic and anaerobic organisms. The duration of preoperative hospital stay, operating time and intraoperative bile spillage were noted for each patient. The patients were evaluated on post-operative days 1, 7, 14 and 30 to look for any evidence of wound infection. Step-wise logistic regression analysis was performed to evaluate the factors influencing the occurrence of wound infection. Wound infection developed in 7/113 patients (6.3%) and was more common in patients who were positive for nasal Staphylococcus aureus (7.3% v. 4.1%, p not statistically significant), bactibilia (12.7% v. 1.5%, p < 0.01) and wound contamination at the time of surgery (13.9% v. 1.3%, p < 0.04). Step-wise logistic regression analysis showed a 13.2 times higher incidence of wound infection in patients who had bactibilia. Bactibilia is the most important predictor of wound infection in low-risk patients undergoing elective LC. As it may not be possible to diagnose which patients have bactibilia by routine investigation, it is advisable to use prophylactic antibiotics to reduce the incidence of wound infection.

Knowledge, attitude and practices towards HIV among nurses in a tertiary care teaching hospital: two decades after the discovery.

Accidental transmission of HIV infection to health care workers during occupational exposure is a real threat today. The first such case in India has been documented by NACO recently. Adequate knowledge about the disease and practice of safety measures are our best bet to reduce such transmission. A survey was carried out amongst over 500 nurses in a tertiary care referral hospital in Delhi to assess their knowledge, attitude and practices towards HIV/AIDS. While overall knowledge was satisfactory, there were gaping holes in vital areas. The conversion of their theoretical knowledge into safe practices was shockingly poor. It was due to attitude problems as much as inadequate supplies. High incidence of accidental exposures in the near past and complete ignorance of post-exposure prophylaxis guidelines was another highlight of this study. Despite tremendous efforts put in by the Government as well as various Non-Governmental Organizations, we are completely ill equipped to fight the menace of occupational HIV transmission. In order to fight this menace, "safe practices" have to be made a "way of life" for HCWs. Our health care planners need to take note of it and our teaching and training programmes need complete re-orientation to achieve this goal.

Pseudoaneurysm of inferior epigastric artery following abdominal paracentesis.

We report a 31-year-old man with chronic renal failure and ascites who developed severe abdominal pain and a local non-pulsatile mass after therapeutic paracentesis. Doppler study confirmed a pseudoaneurysm of the right inferior epigastric artery. The patient recovered after the artery was ligated and the aneurysm excised.

Intercostodiaphragmatic hernia secondary to a bull gore injury: a delayed detection.

We report a case of a 45-year-old male presenting with asymptomatic right lower chest mass following a forgotten penetrating trauma. This case highlights a rare; delayed complication of lower chest penetrating injuries by the bull gore, involving the diaphragm. Intercostodiaphragmatic hernia should be kept as a differential diagnosis of slowly growing lower chest wall asymptomatic masses with forgotten injuries in the past.

Initial experience with day case laparoscopic cholecystectomy at a tertiary care hospital in India.

BACKGROUND: Cholecystectomy is one of the commonest general surgical operations. Laparoscopic cholecystectomy is currently the most favoured approach. As it is associated with less postoperative pain and ileus, it allows early discharge of patients from the hospital. Studies from the West have reported that 'day case laparoscopic cholecystectomy' is feasible and safe. In India, the current practice is to admit patients for laparoscopic cholecystectomy 24-48 hours prior to surgery and to discharge most patients within one to two days of surgery. There is no report from any Indian centre describing 'day case laparoscopic cholecystectomy'. We conducted a prospective study to assess the feasibility, safety and patients' acceptance of 'day case laparoscopic cholecystectomy' in a tertiary care hospital. METHODS: Eighty-four patients with symptomatic cholelithiasis, aged less than 65 years with ASA grade I and II, were offered day case laparoscopic cholecystectomy. Seventy-four patients consented to be included in the study. The nature of operation and likely postoperative course were explained in detail to the patients. Conventional 4-port laparoscopic cholecystectomy was attempted in all patients. The main outcome measures assessed were successful management of patients on day case basis and its acceptance by the patients. RESULTS: Sixty-eight (92%) patients underwent successful laparoscopic cholecystectomy. Fifty-five of these (81%) were successfully managed as day case procedures. There were no major complications. Three of the 55 patients (5.4%) needed re-admission and could be managed conservatively. Fifty-three (96%) patients described their experience as 'pleasant'. None of them described their experience to be 'unpleasant' or 'bad'. Fifty-four (98%) patients stated that they would recommend day case laparoscopic cholecystectomy to close friends and relatives. CONCLUSION: In selected patients, day case laparoscopic cholecystectomy is safe and feasible in a developing country.

Risk factors for wound infection following elective cholecystectomy.

A study of risk factors for wound infection among patients undergoing elective cholecystectomy was undertaken. Over a 2-Year period 177 patients who underwent elective cholecystectomy for symptomatic gall stone disease were randomized into groups, one receiving antibiotics (96 patients) and the other not receiving antibiotics (81 patients). Gall bladder bile and wound swab were cultured to detect bacterial growth. Duration of preoperative hospital stay, type of skin incision and operating time were noted for each patient. Postoperatively wound infection developed in 22/177 (12%) patients. The infection rate was lower in the antibiotic group 3/96 (3%) as compared to the non-antibiotic group 19/81 (23.5%). Wound sepsis occurred in 11/37 (23%) of patients with bactibilia as compared to 11/140 (7.8%) patients with sterile bile. Stepwise logistic regression analysis showed that bactibilia and use of prophylactic antibiotics were the most significant predictors of wound infection in low risk patients undergoing elective cholecystectomy.

Early oral feeding after elective colorectal surgery: is it safe.

The authors have carried out a prospective trial to assess the safety, tolerability and outcome of early resumption of oral feeding after elective abdominal surgery involving the small or the large bowel. Over the study period, 161 patients undergoing elective laparotomy and bowel resection were randomized to two groups. Patients undergoing laparoscopic surgery were not included. In both groups, the nasogastric tube was removed immediately after surgery. In group I, oral feeding was started on first postoperative day, beginning with clear fluids and gradually progressing to a normal diet over a period of 24 to 48 hours, as tolerated. In group II, oral feeding was started after resolution of postoperative ileus, starting again with clear fluids as in group I. The resolution of postoperative ileus was defined as having bowel movements with no abdominal distention or vomiting. In both groups, nasogastric tube was reinserted if the patient had two episodes of vomiting of more than 100 ml over 24 hours in the absence of bowel movements. Postoperative analgesia was similar in both groups and same criteria for discharge from the hospital were followed. Of the 161 patients, 80 were in the early feeding group and 81 in the other group. The age and sex distribution of the patients in both groups was similar. In both groups, segmental colonic, rectal or small bowel resection was the commonest surgery. In group I, 79% patients tolerated feeds compared to 86% in group II. The incidence of vomiting was thus 21% in group I and 14% in group II, the difference being statistically insignificant. Reinsertion of nasogastric tube was required only in 11% patients in group I and 10% patients in group II. Further, the length of postoperative ileus (3.8 + 0.1 vs 4.1 + 0.1 days), length of hospital stay (6.2 + 0.2 vs 6.8 + 0.2 days) and incidence of complications (7.5% vs 6.1%) were not significantly different between the two groups. However, regular diet was tolerated significantly earlier. (p <0.001) in group I as compared to group II (2.6 + 0.1 vs. 5.0 + 0.1 days). Further, there was no incidence of anastomotic leaks or aspiration pneumonia, complications which could be expected to occur secondary to early feeding. The authors have reviewed the literature which shows a trend towards decreasing use of routine postoperative nasogastric drainage. Based on the results of the current study, they suggest that there is no need to delay oral feeding till resolution of colonic ileus as early feeding is safe and well tolerated. They also suggest that early resumption of oral feeding may have a positive impact on the psychological state of the patient and may help the recovery.

Hepatic artery aneurysm.

A 25-year-old man who presented with recurrent attacks of acute abdominal pain was diagnosed to have recurrent attacks of acute pancreatitis with pseudocyst formation. Laparotomy revealed aneurysm of the hepatic artery which was successfully managed with endoaneurysmorraphy.