Bespoke regional blocks for axillary sentinel node biopsy.

INTRODUCTION: Axillary sentinel node biopsy for melanoma is routinely performed under general anaesthesia. Emerging evidence has shown general anaesthetics are associated with increased mortality in the context of the COVID-19 pandemic. In the interest of patient safety, we have designed a series of bespoke axillary regional blocks enabling surgeons to remove nodes up to and including level III without the need for a general anaesthetic. The aim of this study was to assess the feasibility of performing axillary sentinel node biopsy under such blocks. METHODS: Approval was granted by the Joint Study Review Committee on behalf of the Research and Ethics Department. Ten consecutive patients having axillary sentinel node biopsy for melanoma were included in this prospective study. Patients completed a Quality of Recovery-15 (QoR15) questionnaire preoperatively and 24 h postoperatively. DISCUSSION: One patient had a positive sentinel node, the remining were negative. A significant reduction in time spent in hospital post-operatively (p = 0.0008) was observed. QoR15 patient reported outcome measures demonstrated high levels of satisfaction evidenced by lack of statistical difference between pre and post-operative scores (p = 0.0118). 80% of patients were happy to have a regional block and 90% were happy to attend hospital during the pandemic. CONCLUSION: ASNB under regional block is safe, negates risks associated with performing GAs during the COVID-19 pandemic and facilitates quicker theatre turnover and discharge from hospital. Collaboration between anaesthetic and surgical teams has enabled this change in practice. There is a learning curve with both patient selection, education and development of technique.

Beware flammable fingernails. case report: synthetic fingernails result in full thickness burn and terminalisation.

Having long artificial (acrylic) nails is a current fashion trend, and they are becoming an increasingly popular cosmetic enhancement. We believe that they can be a potential burn hazard to their unknowing users. We present the first reported case in medical literature of a woman whose acrylic nail ignited from a cigarette butt a short distance from the nail while she was taking the final puffs. She sustained a full thickness burn to her dominant left thumb, resulting in terminalisation. Acrylic nails are very flammable and, once ignited, they burn to completion, with the source of flame removed. The temperature at the end of a cigarette can reach 900oC when the smoker takes a puff, which would explain how the artificial nail in our case study ignited. The flammability hazard of artificial fingernails is apparently well known in the beautician community. There are multiple beauty websites and blogs raising awareness of the danger of synthetic nails catching fire. We feel this potential risk should be further highlighted to the public.

Le port d'ongles factices en acrylique est un artifice cosmétique à la mode actuellement. Nous pensons que ses utilisateurs ignorent leur danger potentiel. Nous présentons le premier cas de brûlure à cause de ces dispositifs. Il s'agit d'une patiente dont le faux ongle en acrylique a pris feu alors qu'elle tirait les dernières bouffées de sa cigarette, dont l'extrémité enflammée était donc très proche de ses ongles. Il en est résulté une brûlure profonde du pouce gauche (main dominante) ayant nécessité une amputation. Les ongles acryliques sont hautement inflammables, la combustion étant complète même quand a source de chaleur a été retirée. La température de 900°C atteinte à l'extrémité d'une cigarette quand le sujet tire une bouffée peut expliquer la mise à feu de l'acrylique. L'inflammabilité des ongles acrylique semble bien connue dans le monde de la cosmétique, puisque l'on trouve de nombreux avertissements à ce sujet sur les sites et blogs dédiés. Ce risque devrait être mieux transmis au grand public.

Melanoma in buckinghamshire: data from the inception of the skin cancer multidisciplinary team.

Background. Melanoma incidence is increasing faster than any other cancer in the UK. The introduction of specialist skin cancer multidisciplinary teams intends to improve the provision of care to patients suffering from melanoma. This study aims to investigate the management and survival of patients diagnosed with melanoma around the time of inception of the regional skin cancer multidisciplinary team both to benchmark the service against published data and to enable future analysis of the impact of the specialisation of skin cancer care. Methods. All patients diagnosed with primary cutaneous melanoma between January 1, 2003 and December 3, 2005 were identified. Data on clinical and histopathological features, surgical procedures, complications, disease recurrence and 5-year survival were collected and analysed. Results. Two hundred and fourteen patients were included, 134 female and 80 males. Median Breslow thickness was 0.74 mm (0.7 mm female and 0.8 mm male). Overall 5-year survival was 88% (90% female and 85% male). Discussion. Melanoma incidence in Buckinghamshire is in keeping with published data. Basic demographics details concur with classic melanoma distribution and more recent trends, with increased percentage of superficial spreading and thin melanomas, leading to improved survival are reflected.

Guidelines for the excision of cutaneous squamous cell cancers in the United Kingdom: the best cut is the deepest.

Surgical excision remains the gold standard for the management of cutaneous squamous cell cancers (SCC) and national guidelines for operative radial margins predict 95% oncological clearance with a margin of 4 mm for low-risk and 6 mm for high-risk tumours. We retrospectively analysed all cutaneous SCC excisions performed across 4 regional Plastic surgical units in England over a consecutive 24-month period and collected data on tumour characteristics, operative and histological margins and completeness of excision. We identified 633 eligible SCC excisions of which 265 (42%) were over 2 cm in diameter with 37 recurrent tumours (5.8%). The mean radial operative margin was 6.5 mm across all tumours and 8.4 mm for tumours greater than 2 cm. The mean histological tumour diameter was 21 mm. The overall incomplete excision rate was 7.6% (7.9% for tumours >2 cm). Ninety-four percent (45/48) of incomplete excisions involved the deep margin and only 3 out of 633 excisions (0.47%) were incomplete at a radial margin only. No differences were observed in tumour size or excision margin between incompletely and completely excised tumours. Incomplete excisions were most common on the ear, nose and cheek. In summary our analysis demonstrates that despite adherence to recommended surgical margins for cutaneous SCCs the incomplete excision rate remains higher than expected. We believe that this is because most incomplete excisions are incomplete at the deep margin and question the utility of performing increasingly wide excisions, and, the generalisability of the evidence upon which recommendations for radial margins are based.

Breast reconstruction with deep inferior epigastric perforator flaps.

INTRODUCTION: Approximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway. METHODS: A retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010. RESULTS: Overall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28-70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%). CONCLUSIONS: DIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.

Review of open and minimal access approaches to oesophagectomy for cancer.

BACKGROUND: Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit. METHODS: Demographic and clinical data were entered into a prospective database. MIO was thoracoscopic-laparoscopic-cervical anastomosis, hybrid surgery was thoracoscopic-laparotomy or laparoscopic gastric mobilization-thoracotomy, and open resections were left thoracoabdominal (LTA), Ivor Lewis (IL) or transhiatal oesophagectomy (THO). RESULTS: There were 118 resections for carcinoma (23 squamous cell carcinoma, 95 adenocarcinoma) and three for high-grade dysplasia. MIO took longer than open surgery (median 6·5 h versus 4·8 h for THO, 4·7 h for IL and LTA). MIO required less epidural time (P < 0·001 versus IL and LTA, P = 0·009 versus thorascopic hybrid, P = 0·014 versus laparoscopic IL). Despite a shorter duration of single-lung ventilation with MIO compared with IL and LTA (median 90 versus 150 min; P = 0·013), respiratory complication rates and duration of hospital stay were similar. There were seven anastomotic leaks after MIO, four after hybrid procedures and one following open surgery. Mortality rates were 2, 6 and 2 per cent respectively. Lymph node harvests were similar between all groups, as were rates of complete (R0) resection in patients with locally advanced tumours. CONCLUSION: MIO is technically feasible. It does not reduce pulmonary complications or length of stay. Oncological outcomes appear equivalent.

Elevated serum calcium concentrations in mammary tumor bearing C3H/Fg mice without bony metastases.

Sera from eight adult C3H/Fg mice bearing spontaneous mammary gland tumors were analyzed for calcium content in two successive weekly samples. The sera from six mice were fount to have significantly elevated serum calcium concentrations while sera from two were normocalcemic. Intramuscular implantation of mammary gland tumors into 12, 3-month-old female C3H/Fg mice resulted in significant and progressive increases in serum calcium concentrations over a 4-week period. Subcutaneous implants had a similar effect, but gave less consistent results. These data supported the hypothesis that mammary gland tumors are capable of inducing elevated serum calcium concentrations in C3H/Fg mice. It was concluded that low grade elevation of serum calcium occasionally seen in adult female C3H/Fg mice may be caused by incipient mammary gland tumors.