Current controversies in breast cancer surgery.

Contemporary management of the axilla in breast cancer surgery remains in evolution. Axillary lymph node status in breast cancer is a major prognostic factor and remains integral to guiding adjuvant treatment decisions. There remains controversy regarding the management of the node-positive axilla in clinically node-negative primary breast cancer. Trials to date have suggested re-evaluation of the historical therapeutic strategy that a positive sentinel node requires axillary node dissection. However, further evidence is required before modern clinical management of the axilla should be altered. As patient awareness and technical expertise grow, national rates of breast reconstruction after mastectomy continue to rise. Oncoplastic techniques continue to evolve and many patients are suitable for a plethora of reconstructive options. Despite the widespread practice of breast reconstruction globally, there is limited randomised evidence comparing the optimal type and/or timing of breast reconstruction on which to base practice. Breast reconstruction type is either purely autologous, implant-based or a combination of these two techniques. We explore the benefits and limitations of these techniques and some of the key findings of the National Mastectomy and Breast Reconstruction Audit. The timing of reconstruction after mastectomy is either immediate (a single procedure) or delayed (for an indefinite period after mastectomy). The ideal reconstruction is one that is best aligned to the patient's expectations, as this will achieve the highest levels of long-term patient satisfaction. Selecting the optimal type of breast reconstruction at the right time for the right patient remains the key challenge in breast reconstruction.

The role of oncoplastic therapeutic mammoplasty in breast cancer surgery--a review.

BACKGROUND: Reduction mammoplasty is an established technique for symptom relief in women with breast hypertrophy. Therapeutic mammoplasty and radiotherapy may allow cancers to be surgically treated whilst maintaining oncological safety and improving cosmetic outcome. This article aims to review the evidence upon which therapeutic mammoplasty is based and to outline an approach for surgical planning and selection. METHODS: A systematic PubMed and Medline literature search was carried out. All abstracts were studied and papers that dealt primarily with breast conservation using plastic surgery techniques were reviewed. RESULTS AND CONCLUSION: Therapeutic mammoplasty is a useful procedure for breast conserving cancer surgery in women with large breasts, conferring a good cosmetic and functional outcome. This article proposes that breast surgeons experienced in oncological surgery can safely resect tumours from all aspects of the breast with a minimal number of variations in standard mammoplasty technique.

Management of perforated peptic ulcer in a district general hospital.

INTRODUCTION: Laparoscopic surgery has become increasingly popular for elective surgery but it has gained slow transference to emergency surgery. The management of perforated peptic ulcers (PPU) laparoscopically is an accepted strategy yet it still remains infrequently used. The purpose of this study was to analyse the utility and outcomes of laparoscopy versus open repair for PPU in a district general hospital. In addition, we evaluated whether the subspecialty of the on-call consultant affected the method of repair performed and the training opportunities for trainee surgeons. METHODS: Between 2003 and 2009, 53 patients underwent laparoscopic repair, 89 patients underwent open repair and a further 20 patients had laparoscopic repair that was converted to open repair for PPU. The results from a prospectively compiled database were analysed with primary outcome measures including operative time, length of hospital stay and mortality. RESULTS: The median operating time in the laparoscopic group was 60.0 minutes compared with 50.5 minutes in the open group. Hospital stay in surviving patients was significantly shorter in patients treated completely laparoscopically (5 days) when compared with the open group (6 days) ( p <0.01). There were six deaths in the laparoscopic group (11%) compared with 13 in the open group (15%) and one in the converted group (5%). Trainees performed 53% (47/89) of open repairs and 13% (7/54) of laparoscopic repairs. CONCLUSIONS: Both laparoscopic and open repair are equally safe in the management of PPU. Our findings support the view that this procedure can be successfully used as a training operation.