Low axillary sampling in clinically node-negative operable breast cancer.

BACKGROUND: Targeted sentinel node biopsy has been extensively validated. It has been incorporated into standard guidelines for axillary prediction in women with clinically node-negative operable breast cancer. However, the high cost of the gamma probe and the need for radiocolloid have limited its widespread acceptance in developing countries. We aimed to validate low axillary sampling as a reliable alternative method to sentinel node biopsy in a developing country. METHODS: An anatomically guided low axillary sampling removes the lower level I axillary fat with lymph nodes and the method was validated by completing axillary clearance in all women. RESULTS: Three hundred fifty-five women with clinically node-negative operable breast cancer underwent validation of low axillary sampling, with lymph nodes identified in all of them. The median number of nodes identified in low axillary sampling was 5 with overall node-positivity of 32.1% (114 of 355). Ten of these 114 patients were wrongly identified as node-negative by the sampled lymph nodes, i.e. a false-negative rate of 8.8%. Further exploratory analysis showed that 6-node low axillary sampling gave an excellent false-negative rate of 1.5% with 95% sensitivity, which was comparable with the highly targeted sentinel node biopsy technique. CONCLUSIONS: With an overall false-negative rate of 8.8% with 5-node low axillary sampling, and even better false-negative rate of 1.5% with 6-node low axillary sampling, axillary sampling is a low-cost technology, which is a reliable alternative to sentinel node biopsy for axillary nodal prediction in clinically node-negative breast cancer.

Application of Six Sigma towards improving surgical outcomes.

BACKGROUND/AIMS: Six Sigma is a 'process excellence' tool targeting continuous improvement achieved by providing a methodology for improving key steps of a process. It is ripe for application into health care since almost all health care processes require a near-zero tolerance for mistakes. The aim of this study is to apply the Six Sigma methodology into a clinical surgical process and to assess the improvement (if any) in the outcomes and patient care. METHODOLOGY: The guiding principles of Six Sigma, namely DMAIC (Define, Measure, Analyze, Improve, Control), were used to analyze the impact of double stapling technique (DST) towards improving sphincter preservation rates for rectal cancer. RESULTS: The analysis using the Six Sigma methodology revealed a Sigma score of 2.10 in relation to successful sphincter preservation. This score demonstrates an improvement over the previous technique (73% over previous 54%). CONCLUSIONS: This study represents one of the first clinical applications of Six Sigma in the surgical field. By understanding, accepting, and applying the principles of Six Sigma, we have an opportunity to transfer a very successful management philosophy to facilitate the identification of key steps that can improve outcomes and ultimately patient safety and the quality of surgical care provided.

Modification in the technique of pancreaticoduodenectomy: supracolic division of jejunum to facilitate uncinate process dissection.

Pancreaticoduodenectomy remains the recommended procedure for periampullary and pancreatic head tumors. The dissection of the uncinate process from the superior mesenteric vessels is a key step in this surgery. We describe a modification in the existing practice of infracolic division of the jejunum in order to facilitate this step. In this modification, the duodenojejunal (DJ) flexure and the proximal jejunum are delivered into the supracolic compartment and then the jejunum is divided. This exposes the uncinate process completely and facilitates the separation from the Superior Mesenteric Artery (SMA) and the Superior Mesenteric Vein (SMV). We have successfully employed this modified technique for 33 resections since February 2004. This modification of dividing the jejunum in the supracolic compartment is based on sound anatomic and embryologic grounds. It helps in aligning the uncinate process with the jejunal mesentery thereby making the dissection of uncinate process from the superior mesenteric vessels safe and complete.

Chronic arsenic poisoning: a global health issue -- a report of multiple primary cancers.

Chronic arsenic (As) poisoning is a worldwide public health problem. Effects of prolonged exposure to high levels of As in drinking water have been observed and documented in various epidemiological studies from all over the world. The non-malignant cutaneous effects of chronic exposure to inorganic As are well known. A case presenting with multiple cutaneous cancers as well as an internal lung primary in a patient exposed to toxic levels of As in the drinking water is discussed along with a review of literature.

Breast conservation treatment in women with locally advanced breast cancer - experience from a single centre.

INTRODUCTION: In absence of randomized evidence to support safety of conservative surgery (BCT) in locally advanced breast cancer (LABC), we analyzed a cohort of 664 women with LABC treated during January 1998 to December 2002 at Tata Memorial Hospital, Mumbai, India. MATERIALS AND METHODS: All were treated with a multimodality regimen comprising of neoadjuvant chemotherapy (NACT) followed by surgery (modified radical mastectomy or BCT) and adjuvant radiotherapy and hormone therapy. The outcome was evaluated to assess safety of BCT. RESULTS: 71% (469/664) women responded to NACT (22% clinical CR and 49% PR) and 28.3% (188/664) underwent BCT. Positive lumpectomy margins were reported in 8.5%, with gross presence of tumor at the margins in 2.3% requiring a revision surgery. At a median follow-up of 30months, local relapse rate was 8% after BCT and 10.7% after mastectomy. The 3-year local DFS was better post-conservation than after mastectomy (87% vs 78%, P=0.02). The disease-free survival (DFS) was also superior after BCT, 72% vs 52% (P<0.001) at 3years and 62% vs 37% (P<0.001) at 5years respectively. On multivariate analysis, presence of lymphatic vascular emboli (LVE) was the major significant predictor of local recurrence (P<0.001, HR 2.52, 95% CI 1.52-4.18). DFS was better after BCT [(P<0.001, HR 2.0 (95% CI 1.38-2.91)]; shorter DFS was noted in LVE positive (HR 1.54, P=0.007) and larger residual disease after NACT (HR 1.13, P=0.001). CONCLUSION: BCT is technically feasible and safe post neo-adjuvant chemotherapy in women with LABC with no detriment in outcome.

Antimicrobial effect of ciprofloxacin, povidone-iodine, and gentamicin in the decontamination of human donor globes.

PURPOSE: Clinical research addressing the issue of donor globe decontamination is yet to establish convincing data for the optimal choice of an antimicrobial agent. METHODS: In a donor-globe decontamination study, the antimicrobial effectiveness of a fluoroquinolone antibiotic (ciprofloxacin, 0.3%) was evaluated for the first time and compared with povidone-iodine (P-I, 5%) and gentamicin (0.3%). RESULTS: Ciprofloxacin and gentamicin were found to be less effective than P-I (p < 0.05) in converting culture-positive donor globes to culture negative. In eliminating coagulase-negative staphylococci that predominated the bacterial spectrum, again P-I scored better than ciprofloxacin (p = 0.003) and gentamicin (p = 0.006). Overall, P-I performed better than the other two in the 3-min decontamination procedure. Decontamination was carried out with the same agent for 15 min to assess the effect of duration of decontamination on the antimicrobial activity of P-I. With time, there was no significant increase in the antimicrobial efficacy of the agent except for Corynebacterium species. CONCLUSION: P-I continues to be the preferred agent for decontaminating donor globes. Whereas a contact of 3-min duration between P-I and donor globe remains satisfactory in decontamination procedures, corneal tolerance of this procedure needs investigation.

Treatment of acute bacterial infections of the upper respiratory tract.

An open comparative study was carried out to assess the effectiveness of 4 antibiotic regimens in eradicating acute bacterial infections of the upper respiratory tract. Patients in each treatment group had similar physical parameters, severity of disease and bacterial pathogens, and were treated for 10 days with either erythromycin estolate, erythromycin stearate, ampicillin or oxytetracycline in the recommended dosage. Each patient was reviewed daily by physical examination and the bacteriological findings from throat swab and salivary washings. The results showed that erythromycin stearate produced more rapid bacterial eradication and clinical resolution of symptoms and fever than with the other antibiotic preparations, and was well tolerated by most patients.