Healthcare delivery to elderly and unfit patients with breast disease and comorbidities under an outpatient regime: A report of a personal surgical technique named "Cut&Sew".

Introduction: A growing need for proper geriatric assessment and short-stay surgical programs supported by the availability of less invasive approaches, even in ambulatory settings, is being recognized as a feasible option for breast cancer patients with comorbidities who are usually distressed after standard surgery with ordinary hospitalization. Few studies have been conducted in Italian breast centers with dedicated techniques and approach for frail patients with breast diseases due to a jeopardized approach to ambulatory surgery among institutions. Methods: This study included 58 women diagnosed with breast disease and comorbidities between March 2019 and December 2022 at the Ambulatory of Senology of San Giacomo Hospital in Novi Ligure (AL, Italy) and Civil Hospital in Ovada (AL, Italy). The patients were evaluated by a multidisciplinary consensus according to the guidelines provided to limit sentinel lymph node biopsy (SLNB) in older women. This kind of ambulatory surgery technique has been designed for i) patients with advanced age and/or comorbidities, ii) frail patients who psychologically do not accept other kinds of surgery, iii) patients who do not require SLNB, and iv) patients who need a surgical biopsy for lesions classified as B3 or small lesions with dubious radiological imaging. With this technique, the quadrant and whole breast may be removed in an outpatient setting with local anesthesia to limit blood loss by immediately cutting and suturing small portions of the gland. Local anesthetic infiltration is sequential and occurs stepwise before providing short passages of approximately 2 cm during resection and immediately suturing the surgical wound. This overclock technique, named "Cut&Sew," requires no more than 20-25 min and allows for a 1-2 h patient discharge with no drainage. The follow-up period was set at 60 months during routine yearly visits. Results: The patients were older or super-older with most primary pT1/pT2 tumors and ductal type cancers, which were distributed in molecular subtypes Luminal A (37.1 %) and Luminal B (41.5 % Luminal B, with 11.2 % being HER2 positive). The tumour grade was mostly G2-G3. Mastectomy was performed in 10 patients, whereas quadrantectomy was performed in 48 patients, with the majority of tumors localized in Q1.While accompanied by a relative or a caregiver, all 58 patients acceded the "Cut&Sew" surgical technique in an ambulatory setting reporting negligible pain during the surgery and no pain within 10 days post-surgery. No post-operative complications or readmissions were recorded, and no discomfort or recurrence was detected during scheduled visits. Finally, the extent of satisfaction with the overall surgery was recorded immediately and corroborated by most patients during the follow-up period. Conclusions: Although the small volume of cases collected does not allow for a controlled study necessary to evaluate the safety and efficacy of this technique for approaching frail and older women with comorbidities, through the "Cut&Sew" surgical technique, frail, older, and super older patients may benefit from a minimal psychological impact of surgery, while improving the patients' disease-free life so to corroborate the advised surgical de-escalation but avoiding undertreatment for this kind of patient category. Moreover, a stricter assessment of patient pain and overall satisfaction with the collection of a larger amount of reliable data could allow this technique to be extended to frail and/or older patients as a valuable and safe alternative to the more common hospitalization with general anesthesia. Other advantages include reduced hospitalization costs for sanitary structures.

Laparoscopic Splenectomy of a Wandering Pelvic Splenomegaly in a Young Woman Treated in Childhood with Surgery for Diaphragmatic Hernia and Adhesiolysis for Intestinal Obstruction.

BACKGROUND Wandering spleen (WS) is a rare medical condition in which the spleen migrates from its usual position commonly to the pelvis or lower abdomen assuming an ever-wandering state. The incidence of ectopic spleen is 0.2%, with variable clinical manifestations from asymptomatic to abdominal emergency. Symptoms are most attributed to complications related to torsion, so that a nonoperative management of a WS is not advised. According to the literature, 69.5% of patients with WS need splenectomy and 78.6% need laparotomy. CASE REPORT The patient exhibited vague intermittent lower abdominal pain for 6 months due to progressive torsion of the spleen, which resulted in venous congestion. Abdominal investigation revealed a mobile intra-abdominal mass and parenchymatous consistency in the pelvis. Diagnosis by computed tomography outlined abdominal splenomegaly with abnormal position both of pancreas and stomach. Laparoscopy established a giant spleen, with a lengthened pelvic and twisty vascular pedicle. In its ectopic location, the spleen had dragged the pancreas with it, which had taken a vertical position. The classic splenic ligaments were not recognizable. Spleen was removed with median laparotomic incision. Splenectomy was performed to prevent any traumatic fractures of the spleen, a complete twist of the splenic hilum, and the onset of recurrent acute pancreatitis. CONCLUSIONS Wandering spleen is rare in patients presenting with acute abdominal pain. An approach supported by clinical findings and investigation, even considering splenectomy over splenopexy, and laparoscopy over open surgery, may solve and prevent complications and health risks.

Observed outcomes on the use of oxidized and regenerated cellulose polymer for breast conserving surgery - A case series.

BACKGROUND: Oxidized regenerated cellulose polymer (ORCP) may be used for reshaping and filling lack of volume in breast-conserving surgery (BCS). The study aimed to observe both the aesthetic and diagnostic outcomes in patients with different age, BMI, breast volume, and breast tissue composition over 36 months after BCS with ORCP. PATIENTS AND METHODS: 18 patients with early breast cancer and with proliferative benign lesions underwent BCS with ORCP that was layered in three-dimensional wafer, and placed into the Chassaignac space between the mammary gland and the fascia of pectoralis major with no fixation. After surgery, patients started a clinical and instrumental 36-month follow-up with mammography, ultrasonography, magnetic resonance imaging (MRI) and cytological examination with fine needle aspiration when seroma occurred. RESULTS: Below the median age of 66 years old no complications were observed even in case both of overweight, and large breasts with low density. Over the median age seromas occurred with either small or large skin retraction, with the exception of 1 patient having quite dense breasts and low BMI, which had no complications. In elderly patients, 1 case with quite dense breasts and high BMI showed severe seroma and skin retraction, while 1 case with low BMI and less dense breasts highlighted milder complications. CONCLUSION: During 36 months after BCS with ORCP, a significant correlation between positive diagnostic and aesthetic outcomes and low age, dense breasts, and low BMI of patient was observed. Despite of the few number of cases, either low BMI, or high breast density improved the aesthetic outcomes and reduced the entity of complications even in the elderly patients.

Oncoplastic reshaping in breast-conserving surgery in a peripheral hospital. The Novi Ligure "San Giacomo" hospital experience.

AIM: To confirm that oncoplastic approach to cancer is a fundamental part of modern breast conserving surgery also in a suburban hospital. MATERIAL OF STUDY: The Authors used oncoplastic techniques in 60 cases including 45 first level and 15 second level procedures: they show some cases of conservative surgery and breast reshaping with upper, medial and lower pedicle. DISCUSSION: Screening programs are able to identify early breast cancer; the breast conserving surgery with oncoplastic glandular reshaping should be an established custom to ensure oncological safety with the best cosmetic result. CONCLUSIONS: The oncoplastic approach to breast cancer should be the theoretical and practical knowledge of the breast surgeon. Today in fact the breast surgeon must be a "vertical surgeon" in order to treat cancer completely, interfaced with a multidisciplinary team to ensure a personalized treatment for each patient. In this presentation the Authors want to focus on oncoplastic surgery in a medium flow suburban hospital.

Use of oxidized and regenerated cellulose polymer in oncoplastic breast surgery.

AIM: The aim of this paper is evaluate the use of oxidized regenerated cellulose in order to control breast symmetry, shape and volume reducing skin retraction after wide excision for the treatment of early breast cancer. MATERIAL OF STUDY: The Authors describe a new procedure using oxidized regenerated cellulose polymer after 8 resections for breast cancer and 1 total galactophore ducts resection for nipple discharge. DISCUSSION: Oncoplastic breast surgery allows a more radical local tumour excision achieving an acceptable cosmetic result. Breast reshaping absorbs the volume loss and decreases the risk of a localized defect although there are zones that are at high risk of deformity. Once reabsorption of the seroma occurs, the excision cavity becomes prominent due to fibrosis and retraction of the surrounding tissue creating a noticeable defect. CONCLUSIONS: In oncoplastic breast surgery the oxidized regenerated cellulose by preventing the hematoma, can promote dermal fibroblasts proliferation and cell migration playing a role in adjustment of the shape, volume and symmetry of the breast and reducing skin retraction.

An example of lumpectomy for lower inner quadrant breast cancer with 1(st) level oncoplastic reconstruction by glandular splitting.

Oncoplastic techniques extend the scope for breast conserving surgery by combining an extensive local excision with a simultaneous reconstruction of the defect to avoid local deformity. If less than 20% of the breast volume is excised a level I procedure is adequate and can be performed by breast surgeon without specific training in plastic surgery. For breast cancer is possible to fill the defect of the lower inner lumpectomy by splitting the upper inner quadrant. The Authors describe a novel technique in giant breast.

[Haemorrhoidal disease: role of conservative outpatient treatments]. / La malattia emorroidaria: ruolo dei trattamenti ambulatoriali conservativi.

AIM: This study is a critical review of conservative office treatments of haemorrhoidal disease. MATERIAL OF STUDY: Many are outpatient techniques proposed in current literature; several with small series, anecdotal ones or some ones yet abandoned for excessive morbidity (for example anal divulsion, dilatation and so on); among most used we describe procedure, indications, contraindications, results and limits about rubber band ligation, sclerotherapy, cryotherapy, infrared photocoagulation, bipolar diathermy and direct current therapy. RESULTS: Each method has its supporters, indications and limits; therefore in literature there are discordant opinions even when randomized studies are compared. Indeed each technique is been compared with one or more other ones but there is not a randomized trial which compares all these treatments. CONCLUSIONS: Conservative office techniques, and rubber band ligation in particular, have an important role in second degree haemorrhoidal disease, in non-responsive to medical treatment first degree and also in third degree haemorrhoids in elderly patients with comorbidity or with sectorial or moderate prolapse.