Laparoscopically Harvested Omental Flap for Immediate Total Breast Reconstruction; Lessons Learnt Through Ten-Year Experience in a Tertiary Oncology Center.

Background. Most of the publications about Laparoscopically harvested omental flap after skin sparing mastectomy were case reports or case series. Most of them were designed for partial breast reconstruction and were lacking long-term follow-up for cosmetic results, oncologic safety, and detailed methodology. Our study aimed at highlighting the place of this method of reconstruction with long-term oncologic safety and cosmetic outcome. Methods. This study included 95 women who were candidates for skin-sparing mastectomy. Those with body mass index below 25 and above 40, those with omental resection or expected marked adhesions were excluded. All patients were consented to then undergo breast reconstruction using pedicled laparoscopically harvested omental flap. Results. The mean BMI was 34. The mean tumor size was 3.4 cm. The mean total operative time was 129 minutes. Inadequate volume occurred in 12 patients (13%). The mean total drainage output was 750 ml with 8.7% incidence of seroma. Partial breast envelop necrosis was encountered in 5 cases. Partial flap loss occurred in 2 patients. Fat necrosis occurred in 11 cases. Mastectomy and abdominal complications were accepted. Local recurrence was met in one patient and distant metastases occurred in 3 cases. 83.7% of patients expressed excellent and good aesthetic outcomes. Conclusion. When skin sparing mastectomy is chosen with suitable body mass index, laparoscopically harvested omental flap is a very safe and attractive option for total breast reconstruction with a minimal donor site morbidity, satisfactory cosmetic outcome with no compromise of the oncologic safety.

Charcoal Localization for Surgical Resection of Non-Palpable Suspicious Breast Lesions.

Background: Breast cancer is more frequently detected as radiographic non-palpable lesions with the increased utilization of national screening programs. Moreover, the sizes of tumors detected have decreased in recent years, increasing the need for accurate image-directed localization for surgical excision in a significant portion of cases. Although Wire guided localization has been the most commonly used method for many years, inherent problems remain and limit its practice. Radio-guided occult lesion localization (ROLL) is currently the standard method of localization, however, it is unavailable in most low resource communities. This encourages us to use charcoal localization which is a simple and cheap method of surgical localization of non-palpable suspicious breast lesions. Methods: This prospective study included 34 patients who presented with non-palpable suspicious breast lesions (BIRADS 4 or 5). All patients were injected 1-3 ml of sterilized 3% aqueous suspension of charcoal granules under the guidance of ultrasound at the superficial border of the suspicious lesion and the track between the lesion and the needle entry point in the skin which will occur at the future incision. This method was carried out in most patients one day before the operation, however, two patients underwent surgical excision after 6 days of localization without any interruption. Results: Thirty-four patients had 36 Lesions. The median age was 43 years. The mean diameter of lesions was 10.9 mm. Of 36 lesions; the BIRADS as follow10 (4a), 12 (4b), 8 (4c), and 6 (5). Postoperative investigations revealed 16 malignant lesions and 20 benign lesions. All 20 benign lesions were managed by wide local excision; All 14 BIRADS 4a lesions were proved to be benign. Sixteen malignant lesions were managed as the following; nine patients had breast-conserving surgery, five patients had modified radical mastectomy (three patients had past history of modified radical mastectomy, one patient had Multicentric IDC and one patient had infiltrated safety margins on conservation), and one patient had Nipple Sparing Mastectomy with immediate breast reconstruction by Latissimus Dorsi Flap. There was no reaction or infection reported in our study. Conclusion: Charcoal localization has many advantages and helps surgical localization.

Operative Outcomes of Single-Incision Laparoscopic Hysterectomy vs Conventional Laparoscopic Total Hysterectomy: A Prospective Randomized Controlled Study.

Background. Over time, there was an emerging need to shift from laparotomy to minimally invasive laparoscopic surgery, with the success of laparoscopic surgery in the last decade in gyne-oncology. Patients and Methods. This is a prospective randomized controlled trial conducted in Surgical Oncology Unit, Oncology Centre, Mansoura University, in the period between February 2016 and October 2019. Fifty female patients planned for total hysterectomy were randomized into two equal groups; the first underwent conventional laparoscopic hysterectomy (CLH), while the second underwent single-incision laparoscopic hysterectomy (SILH). Results. The mean operative time in the SILH group was 120.00 ± 28.72 minutes vs 103.20 ± 23.04 minutes in the CLH group (P= .027). Median hospital stay in the SILH group was 1 day (range: 1-3 days), the same as that in the CLH group, with no statistical significance (P= .384). Postoperative pain assessment using the Visual Analogue Scale (VAS) after 6 hours had a median score of 6 (2-8) in the SILH group and 6 (4-7) in the CLH group with significant increase in experienced pain in the SILH group (P= .004), while no significant difference was noted after 12 hours and 24 hours in both SILH and CLH groups. Conclusion. Single-incision laparoscopic hysterectomy (SILH) has similar outcomes when compared to conventional laparoscopic hysterectomy as regard blood loss, hospital stay, conversion to laparotomy, intraoperative and postoperative complications with the disadvantages of longer operative time, increased surgeon's workload, and relatively more postoperative pain.

Transanal Versus Laparoscopic Total Mesorectal Excision: A Comparative Prospective Clinical Trial from Two Centers.

Purpose: Laparoscopic total mesorectal excision (LapTME) faced many obstacles in obese male with narrow pelvis and bulky mesorectum with increased risk of incomplete mesorectal excision and positive circumferential resection margin (CRM) and distal resection margin (DRM). Transanal total mesorectal excision (TaTME) is reported to result in a better quality total mesorectal excision (TME) specimen, lower incidence of CRM and DRM involvement, and higher rates of sphincter preservation. To date, there is still a debate about the feasibility and efficacy of transanal versus the laparoscopic approach for TME in middle and low rectal cancer. Materials and Methods: This is a prospective controlled clinical trial where 38 patients of middle or low rectal cancer from two tertiary centers were nonrandomly assigned to either TaTME or LapTME. Results: Eighteen patients were operated by TaTME versus 20 patients by LapTME. Mean body mass index was significantly higher in the TaTME group (30.74 ± 7.79) than in the LapTME group (25.99 ± 4.68) (P = .03). TaTME was associated with more transanal specimen extraction (55.5% versus 20%, P = .06). No significant differences were detected in CRM, DRM, peri- or postoperative complications, or conversion rates with more reported Clavien-Dindo grade III complications in the TaTME group (P = .29). Conclusions: TaTME facilitated rectal cancer surgery in obese patients and increased the chance of transanal specimen extraction with equivalent oncological outcomes to conventional LapTME. Further studies are recommended to build better evidence.

Endometriosis-associated Ovarian Cancer is a Subset With a More Favorable Outcome and Distinct Clinical-pathologic Characteristics.

There is a controversy about whether endometriosis-associated ovarian cancer (EAOC) might represent a different entity from the corresponding ovarian cancer occurring de novo, in the absence of endometriosis. This study investigated the clinical-pathologic characteristics and outcome of EAOC compared with other ovarian carcinomas that are not associated with endometriosis (non-EAOC) in a large cohort. Seven hundred two patients meeting the inclusion criteria were further subclassified as group I when patients had ovarian carcinoma associated with or arising within endometriosis (EAOC) and group II when patients had non-EAOC. Age, gross features, histologic type, International Federation of Gynecology and Obstetrics stage, and disease-free survival (DFS) were compared between the groups. One hundred sixty-eight (23.9%) patients had EAOC, whereas 534 (76.1%) patients had non-EAOC. EAOCs were mostly endometrioid and clear cell type. Patients with EAOC were younger, present early, and had a lower rate of recurrence when compared with patients with non-EAOC, P<0.001. Patients with EAOC had longer DFS time, 51.9 mo (95% confidence interval, 44.9-58.8) versus 30.5 mo (95% confidence interval, 27.7-33.3) in non-EAOC patients. The 5 yr Kaplan-Meier estimate of DFS rate was 70% in 166 patients of group I and was 39.3% in 532 patients of group II, P<0.001. On multivariate analysis, International Federation of Gynecology and Obstetrics staging, histologic type, and treatment were the only significant factors affecting the hazards of recurrence. Patients with tumors associated with endometriosis are usually, younger, present early, have lower rate of recurrence, longer DFS, and their tumors are of lower grade and are more likely endometrioid or clear cell carcinoma.

Preoperative Prediction of Lymph Nodal Metastases in Endometrial Carcinoma: Is it Possible?: A Literature Review.

BACKGROUND: Lymph node status is one of the most important prognostic factors in endometrial cancer and crucial for deciding adjuvant therapy. OBJECTIVE: The aim of the study was to assess the different models used to predict lymphatic nodal disease. SEARCH STRATEGY: A literature search was conducted to detect the relevant studies. INCLUSION CRITERIA: Relevant papers comparing the preoperative modality with the final histopathological results including randomized clinical trials, case-control studies, and any publications with a minimum of 50 patients in the report. RESULTS: Molecular-based predictors are still far from a practical application. Preoperative radiological scans (positron emission tomography, computed tomography, magnetic resonance imaging, and ultrasound) have shown the best predictor of lymphatic dissemination. However, there is currently no ideal model available, which can be used within standard clinical care. CONCLUSIONS: Surgical staging still remains the criterion standard in the determination of lymph node status in endometrial cancer.

Compartmental tongue resection with submental island flap reconstruction for large carcinoma of the oral tongue.

BACKGROUND: Tongue resection is a surgical challenge because of its adverse effects on language articulation, swallowing, respiration, the eventual quality of life, and poor prognosis of advanced disease. To date, the currently accepted standard treatment has been based on excision of the primary lesion with a 1.5-2-cm circumferential macroscopic margin. Compartmental tongue surgery (CTS) is a surgical technique that removes an anatomo-functional compartment containing the primary tumor. METHODS AND TECHNIQUES: This is a prospective study that was carried out from June 2012 to January 2015 for patients with carcinoma affecting oral tongue. We enrolled all cases with ≥T2 tongue cancer with or without infiltration of floor of the mouth. Patients underwent compartmental tongue resection with reconstruction using island submental flap. RESULTS: Pharyngeal tear occurred in two cases that were repaired by simple suture. Bleeding occurred in two cases with control of the affected vessels. Loco-regional recurrence was detected only in two cases that underwent CTS, while 18 patients who underwent traditional tongue resection had local recurrence. CONCLUSION: CTS via pull through technique with submental island flap reconstruction for large tongue cancer has been evolved to improve oncologic resections, obtaining a better local control of disease and increased survival rate with concomitant successful functional and esthetic outcomes especially in elderly patients with serious comorbidities.

Comparative study between uncinate process carcinoma and pancreatic head carcinoma after pancreaticodudenectomy (clincopathological features and surgical outcomes).

BACKGROUND/AIMS: Pancreatic head cancer is considered to have the worst prognosis of the periampullary carcinomas. The clinicopathological features of uncinate process pancreatic cancer are poorly published. METHODOLOGY: We retrospectively studied patients who underwent pancreaticodudenectomy (PD) for pancreatic head adenocarcinoma. This study included three groups of patients. Group A patients with pure pancreatic head carcinoma (PPHC), group B patients with combined head and uncinate process carcinoma (CPHUC) and group C patients with pure uncinate process carcinoma (PUPC). Preoperative, intraoperative and postoperative variables were collected. RESULTS: The study included 157 patients. Jaundice was the most common presenting symptoms in PPHC and CPHUC. Abdominal pain was the most common presenting symptoms in PUPC. The mean common bile duct (CBD) and pancreatic duct diameters were significantly smallest in PUPC group (P=0.0001). The venous invasion was significantly observed more in PUPC group and vascular resection was done in 50% of cases. The number of patients with microscopically residual tumor was significantly highest in PUPC group after PD than in other two groups (P=0.001). Recurrence rate occurred in 54.2% in PUPC group, 34.8% in CPHUC group and 22.7% in PPUC group after PD (P=0.007). The median survival was 19 months in PPHC groups, 16 months in CPHUC group, 14 months in PUPC group (P= 0.02). CONCLUSIONS: PUPC presented with abdominal pain with more vascular infiltration. The recurrence rate was common after PD for uncinate process carcinoma especially locoregional recurrence and the overall survival rate was found to be lower for PUPC.

Therapeutic reduction mammoplasty in large-breasted women with cancer using superior and superomedial pedicles.

BACKGROUND: Surgical management of breast cancer in large-breasted women presents a real challenge. This study aims to evaluate the outcome of therapeutic reduction mammoplasty in large-breasted women with breast cancer using superior and superomedial pedicles, situated at any breast quadrant except for the central and upper medial quadrants. METHODS: Fifty women with breast cancer and large breasts underwent simultaneous bilateral reduction mammoplasty. The weight of the tissue removed ranged from 550 g to 1050 g and the tumor-free safety margins by frozen section were in the range of 4 cm to 12 cm. RESULTS: The age of the patients ranged from 36 to 58 (median 43) years and tumor size ranged from 1 cm to 4 cm. The cosmetic outcomes were excellent in 32 patients (64%), good in 15 (30%) patients, and fair in three patients (6%). The follow-up period was 8-36 (mean 20) months, with no local recurrence or systemic metastasis. CONCLUSION: Therapeutic reduction mammoplasty using superior and superomedial pedicles was shown to be oncologically safer than traditional conservative surgery. This oncoplastic procedure yields a satisfactory esthetic outcome with lower morbidity in large-breasted women with breast cancer.