A 5-year follow-up study of 633 cutaneous SCC excisions: Rates of local recurrence and lymph node metastasis.

BACKGROUND: A 5-year follow-up study of 633 cutaneous squamous cell cancer (SCC) excisions was performed by collecting data on rates of local recurrence (LR) and lymph node (LN) metastasis. METHODS: A retrospective analysis of patients was performed across four regional plastic surgery centres (Stoke Mandeville Hospital, Aylesbury; John Radcliffe Hospital, Oxford; Salisbury District Hospital, Salisbury and Queen Alexandra Hospital, Portsmouth) assessing rates of LR and LN metastasis. RESULTS: We report 5-year outcomes from 598 SCCs (95% follow-up rate). The total recurrence rate (LR and LN metastasis) was 6.7% (n = 40) at 5 years, with 96% of these occurring within 2 years. Median time to LR was 9 months (1-57), with 76.9% (n = 20) undergoing further wide local excision. Median time to LN metastasis was 5.5 months (1-18 months). There were two cases of disease-related death. Only 15% (n = 6) of incomplete excisions recurred. Interestingly, 19.1% (n = 9) of 47 SCCs with perineural invasion on original histopathology recurred versus only 5.6% (n = 31) of the 551 SCCs without perineural invasion (p = 0.005). CONCLUSIONS: This study is one of the largest studies to date following up 598 SCC excisions at 5 years with total recurrence rates comparable to those in current published literature. We report perineural invasion as a significant predictor of recurrence and that 96% of total recurrence occurred within 2 years. This is in contrast to current UK guidelines (75% at 2 years, 95% at 5 years), thus suggesting that shorter length of hospital follow-up may be reasonable.

Infrared evaluation of the heat-sink bipolar diathermy dissection technique.

BACKGROUND: The use of the bipolar diathermy dissection technique is widespread amongst surgeons performing flap perforator dissection and microvascular surgery. The 'heat-sink' modification uses a DeBakey forcep as a heat sinking interposition between the bipolar tip and the main (vascular or flap) pedicle aiming to protect it from the thermal effects of the bipolar diathermy. This study examines the thermal effects of bipolar cautery upon the microvasculature and investigates the efficacy of heat sinking as a thermally protective technique in microsurgical dissection. METHODS: A chicken thigh microsurgical training model was used to examine the effects of bipolar cautery. The effects of bipolar were examined using high definition, real-time infrared thermographic imaging (FLIR Systems) and temperature quantitatively assessed at various distances away from the point of bipolar cautery. Comparison was made using the heat sink technique to determine if it conferred a thermoprotective effect compared to the standard technique without heat sink. RESULTS: Using paired t-test analysis (SPSS) the heat sink modification of the bipolar dissection technique was found to have a highly statistically significant effect (P < 0.000000001) in reducing the conductive temperature along the vascular pedicle. This protective effect kept temperatures comparable to controls. CONCLUSION: Bipolar cautery is an extremely safe method of electrosurgery, however when its use is required within 3 mm of important vascular architecture, the heat-sink method is a viable and easy technique to prevent thermal spread and limit potential coagulopathic changes.

Salvage of failed prosthetic breast reconstructions by autologous conversion with free tissue transfers.

OBJECTIVE: Implant-based breast reconstructions are conceptually simple but prone to surgical revisions. Additional procedures often fail to address the problems associated with the reconstructive outcome, especially in patients who have received radiotherapy. However, conversion to free flaps may improve symptoms and aesthetic results. We reviewed our experience in the United Kingdom with autologous replacement of failed prosthetic reconstructions with the aims of documenting the indications for "tertiary" reconstructions and comparing our outcomes with those of other centers. METHODS: Patients undergoing salvage surgery for suboptimal prosthetic breast reconstructions between 2000 and 2012 were retrospectively reviewed for their original reconstructive operation, previous radiotherapy, indications for revision, corrective procedures undertaken, and final outcomes. RESULTS: Of 14 patients identified, 7 had delayed and 7 had immediate reconstructions. Twelve had received radiotherapy; 6 before the initial delayed prosthetic reconstructions and 6 after immediate reconstructions. Ten patients presented after undergoing previous revisions of their original reconstructions (average 1.6). Indications for autologous conversion were capsular contracture, persistent pain, and poor cosmetic outcomes (often in combination). Salvage comprised explantation, total capsulectomy, and abdominal free flap reconstruction using deep inferior epigastric artery flaps (9) and transverse rectus abdominis myocutaneous flaps (5). The average interval between initial reconstruction and salvage was 8 years (r = 1-14). All flap transfers were successful with satisfactory aesthetic outcomes (average 21 months follow-up). CONCLUSIONS: We recommend early salvage autologous conversion of implant-based reconstructions once initial prosthetic reconstructions become unsatisfactory, particularly in recipients of radiotherapy. Many of these patients may have been better served by initial autologous reconstruction; the challenge is to identify them prospectively.

Systematic review of sentinel lymph node biopsy in anal squamous cell carcinoma.

BACKGROUND: Anal squamous cell carcinoma with lymph node metastases carries a poor outcome. There remains a need for a better method to diagnose inguinal lymph node metastases which is minimally invasive, accurate and avoids unnecessary irradiation to the groin with its associated significant co-morbidity. The aim of this study was to evaluate the role of sentinel lymph node (SLN) biopsy in anal squamous cell carcinoma. METHODS: The systematic review was conducted in accordance with PRISMA guidelines. The Medline, Central and Embase databases were searched using the terms 'sentinel lymph node' and 'anus neoplasms'. RESULTS: The systematic review identified 17 studies, containing 270 patients. SLN detection rate varied from 47% to 100%. The presence of nodal metastases varied from 0 to 44%. The complication rate varied from 0 to 59%. The rate of development of subsequent inguinal lymph node metastases in those previously SLN biopsy-negative (a surrogate marker for false negative rate) ranged from 0 to 18.75%. CONCLUSION: SLN biopsy is a feasible method of assessing lymph node status in patients with anal squamous cell carcinoma. Longer follow up is required to evaluate the proportion of patients who are SLN biopsy-negative and subsequently develop nodal metastases. More studies are required to ascertain whether SLN biopsy should be the main method of assessing inguinal lymph node involvement in patients with anal squamous cell carcinoma.

Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery.

BACKGROUND: Surgical-site infection increases morbidity, mortality and financial burden. The preferred topical antiseptic agent (chlorhexidine or povidone-iodine) for preoperative skin cleansing is unclear. METHODS: A meta-analysis of clinical trials was conducted to determine whether preoperative antisepsis with chlorhexidine or povidone-iodine reduced surgical-site infection in clean-contaminated surgery. RESULTS: The systematic review identified six eligible studies, containing 5031 patients. Chlorhexidine reduced postoperative surgical-site infection compared with povidone-iodine (pooled odds ratio 0.68, 95 per cent confidence interval 0.50 to 0.94; P = 0.019) . CONCLUSION: Chlorhexidine should be used preferentially for preoperative antisepsis in clean-contaminated surgery.