Pectoralis Major Muscle Morbidity After Submuscular Silicone-based Breast Reconstruction: A Systematic Review.

Silicone implants or tissue expanders placed under the pectoralis major (PM) muscle are often used for breast reconstruction. However, the disruption of PM insertions, which is often an inevitable part of the surgical procedure, is known to cause PM morbidity and, subsequently, problems with the use of the ipsilateral arm. In this systematic review, we present current knowledge regarding the effect of submuscular silicone-based breast reconstruction on the function of PM and the ipsilateral arm. A search of the relevant English literature was performed through PubMed and ten eligible studies were identified. Articles reporting breast augmentation were accepted as the techniques of implant insertion are similar to reconstruction. Questionnaires reporting the status of the arm, analysis of the range of motion of the shoulder with 3-D video, isometric or isokinetic dynamometry, ultrasound shear-wave elastography, volumetric MRI, electromyography and light and electron microscopy of the PM fibers were used for the assessment of PM and arm status. The insertion of implants under the PM, especially when combined with dissection of some of its insertions, seems to be associated with measurable abnormal microscopic, imaging, and dynamometric findings. However, the intact part of the muscle and possibly other nearby muscular structures are able to compensate for the lost part of PM. Thus, the insertion of implants fully or partially under the PM seems to have no or little effect on the function of the ipsilateral upper limb in daily life.

Neutralizing antibody responses in healthcare personnel after three doses of mRNA BNT162b2 vaccine and association with baseline characteristics and past SARS-CoV-2 infection.

AIM: To estimate neutralizing antibody (NAb) immunity against SARS-CoV-2 in 739 healthcare personnel (HCP) vaccinated with three doses of BNT162b2 mRNA vaccine. METHODS: Serum samples were collected at 3, 6, and 9 months after the second vaccine dose and at 7-55 days after the third dose. Samples were tested for NAbs against SARS-CoV-2 receptor binding domain. RESULTS: The mean inhibition rates at 3, 6, and 9 months after the second dose were 86.33%, 73.38%, and 61.18%, and increased to 95.57% after the booster dose. Younger HCP and HCP with past SARS-CoV-2 infection had higher inhibition rates while there was an inverse correlation between NAb levels and comorbidities or tobacco use (p-values < 0.001). Increased NAb titers were also noticed in women (p-value = 0.033), especially at the end of the 9-month study period. CONCLUSION: NAb levels increased considerably after a booster mRNA vaccine dose. Host factors and past SARS-CoV-2 infection influence NAb titers.

De-epithelialized Skin Flaps to Minimize Complications in Large Breast Reconstruction: A Tailored Approach.

ABSTRACT: Mastectomy and immediate reconstruction may be challenging in patients with large breasts, especially when significant ptosis is also present. Skin-reducing mastectomy (SRM) is usually indicated in these cases, although with increased morbidity. The aims of the study were to introduce 2 modifications of the classic technique and to incorporate them in the management algorithm to improve the outcomes.Twenty patients fulfilling the criteria for SRM underwent mastectomy and reconstruction either with the "classic SRM" (8 patients) or with 1 of the 2 modifications described here: modification A "vertical limb bridging" (for patients with very large breasts, 2 patients) and modification B "dual coverage" (for patients with moderate breasts, 10 patients). All reconstructions were performed using a slow progressive expansion of the implant. Herein, we describe the techniques along with the proposed indications for each one of them.There was no reconstruction failure, and all patients were satisfied with the final results. There were 2 cases with T junction, lateral skin flap partial ischemia managed with delayed revision of the wound on the fifth postoperative day to allow less skin excision. One patient (smoker) developed severe lower pole cellulitis, which was managed conservatively. Finally, 1 patient who underwent radiotherapy developed a late infected seroma, which was managed successfully with drainage and antibiotics. Overall, there was good lower pole projection even with the dual-coverage modification.Skin-reducing mastectomy can be tailored according to individual patient anatomy, and the high reported complication rate associated with this technique can be minimized using certain surgical modifications, tissue expanders with progressive inflation, and good patient selection.

The value of the intraoperative assessment of the SLN via frozen section in the post Z0011 era.

INTRODUCTION: Sentinel node (SN) assessment via frozen section (FS) has declined since the publication of Z0011 which modified the management of a specific group of patients with positive SN. The risk of misleading the surgeons to a preventable ALND and the cost are among the main factors for that. The aim of our study is to assess the value of FS in the post Z0011. MATERIAL AND METHODS: 244 patients out of 434 were eligible for an upfront SLNB. Based on the final histology and the clinical data we selected the eligible for breast conserving surgery patients (55.4%). 78 patients had positive SN and 26 of them fulfilled the criteria of Z0011. We assessed the false negative findings, the impact on the management and the indications and value of FS in the post Z0011 era. RESULTS: Overall, there were 12 FN cases out of which 7 were macrometastases (8.97%). Only in one case there were > 2 positive LN and 3 patients needed mastectomy. The remaining cases fulfilled the criteria of Z0011 and needed no further surgery hence in 96.1% of the cases the axillary status was correctly assessed via FS and the reoperation rate was 1.2%. On the contrary, if FS was not used, at least 21.3% of the patents would have needed reoperation based on the today's guidelines. DISCUSSION: We believe FS is still valuable and may spare a significant percentage of patients from a second operation (SNB) without leading to axillary overtreatment if used wisely.

Ongoing clinical trials on axillary management.

INTRODUCTION: Within the last 50 years the management of patients with breast cancer has changed dramatically with a significant de-escalation of the role and magnitude of surgery, both for the management of the primary tumor and for the management of the axilla. In the management of the axilla of patients with early stage breast cancer (EBC) and clinically uninvolved axilla (cN0), axillary lymph node dissection (ALND) was gradually replaced by sentinel lymph node biopsy (SLNB) saving more than 60-70% of patients from an unnecessary dissection. Further studies confirmed that isolated tumor cells or micrometastases found on the SLN had no further benefit from ALND sparing even more patients from an unnecessary ALND. Eventually, the Z0011 and other studies showed that even patients with 1-2 positive SLN can be spared from ALND provided they fulfill certain criteria. Still though there were many flaws in these studies and further research was necessary to generalize the results of these studies to a wider target group. Meanwhile, there is a clear view that many low risk patients if they have their axilla evaluated via US and are not found to have suspicious nodes, it is highly unlikely to have involved axilla. This let to studies evaluating the non-surgical management of the axilla. Finally, in the post neoadjuvant setting 3 randomized controlled trials showed that under certain circumstances SLNB can be done after the NAC even in patients who initially had involved axilla and was converted to clinically uninvolved (cN1→cN0). EVIDENCE ACQUISITION: PubMed, Medline, the Cochrane Library Controlled Trials Register as well as National Institutes of Health ClinicalTrials.Gov database have been consulted up to May 2020. EVIDENCE SYNTHESIS: We studied and described the ongoing trials on patients not undergoing neoadjuvant chemotherapy and we discussed the eligibility criteria, the comparison arms and the expected outcomes. We further examined the ongoing trials on patients undergoing neoadjuvant chemotherapy in the same manner. CONCLUSIONS: Although we have covered a long way in the journey of eliminating axillary surgery, there are still lots of questions to be answered and trials to be conducted. We anticipate the results of the ongoing trials to provide the necessary evidence to safely de-escalate more the axillary surgery, both in the non-neoadjuvant as well as in the neoadjuvant setting, hoping that in the not so far future the axillary surgery will eventually perish.

The Impact of Educational Status on the Postoperative Perception of Pain.

BACKGROUND: Postoperative (PO) pain interferes with the recovery and mobilization of the surgical patients. The impact of the educational status has not been studied adequately up to now. METHODS: This prospective study involved 400 consecutive general surgery patients. Various factors known to be associated with the perception of pain including the educational status were recorded as was the preoperative and postoperative pain and the analgesia requirements for the 1(st) PO week. Based on the educational status, we classified the patients in 3 groups and we compared these groups for the main outcomes: i.e. PO pain and PO analgesia. RESULTS: There were 145 patients of lower education (junior school), 150 patients of high education (high school) and 101 of higher education (university). Patients of lower education were found to experience more pain than patients of higher education in all postoperative days (from the 2(nd) to the 6(th)). No difference was identified in the type and quantity of the analgesia used. The subgroup analysis showed that patients with depression and young patients (< 40 years) had the maximum effect. CONCLUSIONS: The educational status may be a significant predictor of postoperative pain due to various reasons, including the poor understanding of the preoperative information, the level of anxiety and depression caused by that and the suboptimal request and use of analgesia. Younger patients (< 40), and patients with subclinical depression are mostly affected while there is no impact on patients over 60 years old.

The late effect of intraoperative wound infiltration with local anaesthetic in surgical patients; is there any? A randomized control trial.

INTRODUCTION: Intraoperative wound infiltration with local anaesthetic is commonly used. Apart from the obvious immediate action it has been supported that a possible down regulation of pain receptors may lead to longer effects. Our aim was to compare the use of local anaesthetic versus placebo in order to assess if indeed there is a late beneficial effect. METHODS: We conducted an RCT involving 400 consecutive general surgery patients randomized in 2 groups: Group A = placebo, Group B = wound infiltration with 15 ml of ropivacaine 10%. We recorded the preoperative and postoperative pain for the 1st week as well as the type and quantity of the analgesia used during the study period. RESULTS: No significant difference was found between the groups in all known confounding factors recorded. No significant difference was found in the intensity of postoperative pain. More people of group A required NSAIDs during the first 3 PO days while more people of Group B required stronger painkillers. For those patients who underwent a non urgent operation and especially laparoscopic surgery higher pain score was recorded in the group B from the 3rd PO day onwards. DISCUSSION: Intraoperative local infiltration of the wound with local anaesthetic offers no further benefit for the general surgery apart from that of the immediate PO period. There is no late effect for pain control. Considering that during the immediate postoperative period stronger systematic painkillers are given the intraoperative, infiltration of the wound with the local anaesthetic under study offers no obvious benefit.

Laparoscopic versus Open Adrenalectomy for Stage I/II Adrenocortical Carcinoma: Meta-Analysis of Outcomes.

AIM: The aim of the present meta-analysis was to investigate the safety and oncologic efficacy of laparoscopic adrenalectomy for stage I and II adrenocortical carcinoma. The issue of level I evidence is entirely unreturned. METHODS: Electronic databases were used to search for articles from 1992 to 2014 in the English language literature. The primary end point of the study was to evaluate the safety of the laparoscopic procedure in terms of complications and the oncologic effectiveness of the procedure comparing the R0 resection, disease free survival and overall survival of patients treated with open adrenalectomy versus laparoscopic adrenalectomy. RESULTS: Differences in postoperative complications and R0 resections did not reach statistical significance between treatment arms. There were not statistical significant differences between treatment arms considering the two-year, three-year, four-year overall survival while five-year overall survival was in favor of open adrenalectomy group. There were not statistical significant differences between treatment arms considering the two-year, three-year, four-year, and five-year disease free survival. CONCLUSIONS: It seems that postoperative complications, R0-resection, overall, and disease free survival of stage I/II adrenocortical carcinoma are comparable and independent to the procedure though the five-year survival was in favor of the open group. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

Surgical treatment of primary hyperparathyroidism: description of techniques and advances in the field.

Primary hyperparathyroidism is a disease commonly seen in patients above 60 years of age. It is the most common cause of asymptomatic or symptomatic hypercalcemia, usually found incidentally on routine check-ups. Surgical treatment is the only definitive treatment of choice in the symptomatic patient; however, it can also be employed in asymptomatic patients. First described in 1925, bilateral neck exploration is the gold standard of treatment for primary hyperparathyroidism. The recent interest in minimally invasive surgeries has led to better and improved techniques of neck exploration with improved cosmetic results and lesser chances of transient or permanent hypoparathyroidism due to inadvertent removal of normally functioning parathyroid tissue. These include unilateral neck explorations, minimally invasive parathyroidectomies and minimally invasive radio-guided parathyroidectomy. The intact parathyroid hormone assays have greatly added to the detection of normal and abnormal functioning glands, hence better surgical outcomes.

The value of plasma neurotensin and cytokine measurement for the detection of bowel ischaemia in clinically doubtful cases: a prospective study.

The aim of this prospective study was to examine whether serum neurotensin, interleukin (IL)-6, and IL-8 are early predictor of bowel ischaemia especially in clinically equivocal cases. To this end, 56 patients were assigned to the following groups according to their disease: bowel ischaemia (group 1: n = 14), small bowel obstruction (group 2: n = 12), acute inflammation (group 3: n = 6), perforation (group 4: n = 8), and colorectal adenocarcinoma (group 5: n = 16). Fifteen healthy controls were assigned to group 6. Blood samples were obtained at enrollment, all measurements were done blindly, and all patients underwent surgery. Pretreatment doubtful diagnosis comprised of ileus, mild abdominal pain, and indeterminate imaging. Blood urea nitrogen, lactic acidosis, diagnostic workup, and IL-6 were predictors of diagnosis in univariate analysis. In multivariate analysis, IL-6 (P < 0.001) and diagnostic workup (P < 0.01) were independent predictors of the definite diagnosis. Neurotensin and IL-8 did not differentiate among groups. Considering clinically doubtful cases, IL-6 perfectly differentiates mesenteric ischaemia (of infarction/embolic/occlusive aetiology) from the rest of the indeterminate pathologies. The optimum cut-off point for IL-6 was 27.66 pg/mL. The value of serum IL-6 (27.66 pg/mL) had sensitivity = 1 and specificity = 1. In conclusion, plasma IL-6 measurement on admission might be an additional diagnostic tool that can predict bowel ischaemia in doubtful clinical situations.

Laparoscopic totally extraperitoneal versus open preperitoneal mesh repair for inguinal hernia recurrence: a decision analysis based on net health benefits.

BACKGROUND: The aim of this study is to evaluate the most cost-effective treatment strategy using preperitoneal mesh for patients with recurrent inguinal hernia. Currently, the issue of cost-effectiveness is entirely unresolved. METHODS: A decision analysis was carried out based on the results of a systematic literature review of articles concerning recurrent inguinal hernia repair that were published between 1979 and 2011. A virtual cohort was programmed to undergo three different treatment procedures: (1) laparoscopic totally extraperitoneal hernia repair (TEP), (2) open preperitoneal mesh repair according to Stoppa, and (3) open preperitoneal mesh repair according to Nyhus. We carried out a base-case analysis and varied all variables over a broad range of reasonable hypotheses in multiple one-way and two-way sensitivity analyses. RESULTS: The average cost-effectiveness ratio of Nyhus, Stoppa, and TEP per quality-adjusted life year was US $ ($)1,942, $1,948, and $2,011, respectively. In terms of the incremental cost-effectiveness ratio (ICER), Stoppa was dominated. The choice between TEP or Nyhus procedure depends on the combination of a specific center's rates of recurrence and morbidity as disclosed by three-way sensitivity analysis. CONCLUSIONS: Nyhus and TEP repairs are possible optimal choices depending primarily on the institution's rates of recurrence and morbidity. Based on our net benefit-related decision analysis, a hypothetical "fixed budget trade-off" suggests potential annual incremental health system cost savings of $200,000 attained by shifting care for 1,000 patients from TEP to Nyhus repair (depending on clinical end-points, which is a decisive factor).

Laparoscopic versus open appendicectomy in Greek reality.

Laparoscopic appendicectomy (LA) may be the treatment of choice for acute appendicitis. Our aim was to assess LA in Greek reality. Within a year, 135 patients with a mean age of 29.25 years (14 to 67) underwent an operation for "acute appendicitis." We analyzed the hospital stay, the morbidity, the cost, and the severity of the inflammation and compared the open appendicectomy [OA (78)] with the LA (57) approach. There were no differences in the appendicitis severity (P = 0.667), and similar complication rate (P = 0.414) and mean hospital stay were observed between the groups (LA = 3.18 vs. OA = 2.97, P = 0.664). In the way, medical procedures are priced in Greece; the mean net cost of LA was 1320.60 euros (1748.05 USD), whereas for OA, it was 237.8 euros (314.77 USD). The severity of appendicitis is not a limitation for LA. Because of an insufficient costing system in Greece, the best cost effectiveness is for young women and obese men.

The effect of warm liver ischaemia & reperfusion injury on circulating plasma lipid levels & lipolytic enzyme activity in rat & the impact of ischaemic preconditioning.

BACKGROUND & OBJECTIVES: Ischaemia/reperfusion (I/R) associated with major liver surgery compromises liver function. Ischaemic preconditioning (IPC) may be effective in minimizing hepatic I/R injury. This study aimed to investigate the impact of liver ischaemic manipulations on lipid metabolism in rat during the process of liver recovery after liver surgery. METHODS: Sixty three male Wistar rats were assigned to three groups: the sham group, the I/R group which underwent warm ischaemia and reperfusion (I/R), and the IPC group. The animals were subdivided in 3 groups [1 st , 3 rd and 7 th postoperative day (PO)]. Hepatic lipase (HL) and total lipase (TL) activity and the levels of aspartate and alanine transaminases (AST, ALT), triglycerides, HDL and cholesterol were measured in plasma. RESULTS: There was no significant difference in the activity of HL and TL between the groups. Significant higher levels of HDL (P<0.0001) were observed in the IPC group when compared to the other groups on the 3 rd PO day. Triglycerides (P<0.0001) and HDL (P=0.003) in the IPC group were higher than the sham group on the 7 th PO day while HDL was also higher in the I/R group. Significantly higher cholesterol levels were found in the I/R and IPC groups on the 7 th PO day, which were not observed in the sham group. There was a similar curve for triglycerides in the sham and IPC groups while there were significantly higher levels of triglycerides on day 7 for the I/R group. The levels of HDL in the IPC group were higher on the 3 rd and 7 th PO day, compared to day 1. INTERPRETATION & CONCLUSION: Warm ischaemia and I/R injury do not seem to affect lipolytic enzyme activity after the 1 st PO day despite the effects on plasma lipids. IPC seems to prevent accumulation of triglycerides and cholesterol in plasma.

Incidental findings in trauma patients during focused assessment with sonography for trauma.

During the initial assessment of trauma patients they usually undergo a Focused Assessment with Sonography for Trauma (FAST) in which there are occasionally incidental findings of other surgical conditions. In this audit we discuss the incidence, demographics, and implications of these findings and we propose a management algorithm. Within 2 years we managed 6041 trauma patients in the emergency department based on the Advanced Trauma Life Support protocols, 95 per cent of which underwent a FAST ultrasound. Incidental findings were reported in 468 patients (7.8%), whereas in a further 11.2 per cent of these patients there was a second finding. The mean age of these patients was 57.55 years (15-105), and most of them were men (51.1%). The vast majority of the findings were related to the liver and biliary tree (52.1%) followed by the urinary track (27.1% + 8%). In multivariate analysis only the age was a significant factor associated with incidental findings (P < 0.001) whereas in univariate analysis both the gender [men (54.1%) vs women (45.9), P = 0.013] and the mechanism of trauma (P < 0.001) were as important as the age (P < 0.001). The patients who had incidental findings were 15 years older than the rest. The detection of unknown surgical conditions in FAST may lead to managerial and possible medico-legal issues rendering the development of a proper algorithm mandatory.

The use of neural networks in identifying risk factors for lymph node metastasis and recommending management of t1b esophageal cancer.

The objective of this study was to establish a prediction model of lymph node status in T1b esophageal carcinoma and define the best squamous and adenocarcinoma predictors. The literature lacks a satisfactory level of evidence of T1b esophageal cancer management. We performed an analysis pooling the effects of outcomes of 2098 patients enrolled into 37 retrospective studies using "neural networks" as data mining techniques. The percentages for lymph node, lymphatic (L+), and vascular (V+) invasion in Sm1 esophageal cancers were 24, 46, and 20 per cent, respectively. The same parameters apply to Sm2 with 34, 63, and 38 per cent as opposed to Sm3 with 51, 69, and 47 per cent. The respective number of patients with well, moderate, and poor histologic differentiation totaled 267, 752, and 582. The rank order of the predictors of lymph node positivity was, respectively: Grade III, (L+), (V+), Sm3 invasion, Sm2 invasion, and Sm1 invasion. Histologic-type squamous and adenocarcinoma (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were sm3 invasion and (V+). As concerns ADC, the most important predictor was (L+). Submucosal esophageal cancer should be managed with surgical resection. However, this is subject to the histologic type and presence of specific predictors that could well alter the perspective of multimodality management.

Incidental findings in focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients: speaking about cost to benefit.

BACKGROUND: The purpose of this study was to identify which age-related groups of hemodynamically stable blunt trauma patients will present a positive cost-to-benefit ratio, in regard to the screening of incidental findings on Focused Assessment with Sonography for Trauma (FAST). METHODS: We conducted a prospective study using retrospective data taken from the trauma registry of 6,041 consecutive hemodynamically stable blunt trauma patients who underwent FAST at our Level I urban trauma hospital during the year 2009. A receiver operating characteristic curve was used to determine whether age level is useful in detecting organ-/system-specific incidental findings in trauma patients undergoing FAST and to establish the required diagnostic cutoff value of this selected test. A cost-benefit analysis was then performed for the age-specific cutoff values of each organ/system evaluated by FAST. RESULTS: We found 522 incidental findings in 468 patients (7.8%). Further diagnostic workup was instructed in 35% (168 of 468) of patients with incidental findings. The cost-benefit analysis for the age-specific cutoff values found in the receiver operating characteristic curve analysis showed that the project of screening for incidental findings on FAST was viable only when the ultrasound operator additionally searches the liver/biliary tree (≥43 years) and the kidneys (≥56 years). CONCLUSIONS: A systematic examination of the liver and biliary tree and both kidneys of specific age groups during FAST screening of hemodynamically stable blunt trauma patients may disclose a potentially unknown pathology with a positive cost-to-benefit ratio.