Optimal timing of surgery following breast cancer neoadjuvant chemotherapy: A systematic review and meta-analysis.

BACKGROUND: Administration of chemotherapy before breast surgery has the potential to reduce the risk of distant recurrence by targeting micrometastasis as well as allowing a more minimalistic approach to surgical intervention. We performed a systematic review to determine the optimum timing of surgery post breast cancer neoadjuvant chemotherapy (NACT). METHODS: The primary outcome was to determine whether the timing of surgery post NACT impacted overall survival (OS) and disease-free survival (DFS). We compared patient outcomes between those who had surgery within 8 weeks of completion of NACT to those that had surgery after 8 weeks. An outcome comparison between <4 weeks and 4-8 weeks was also performed. Secondary outcome included complete pathological response (pCR) post NACT. A meta-analysis was performed using the Mantel-Haenszel method. RESULTS: Five studies, including 8794 patients were eligible for inclusion. Patients that had surgery within 8 weeks of completion of NACT had a statistically significant improved OS(OR 0.47, 95% c. i 0.34-0.65) and DFS(OR 0.71 (95% c. i 0.52-0.98, P = 0.04). There were no survival advantages associated with having surgery less than 4 weeks post completion of NACT (OR 0.78, 95% c. i 0.46-1.33, P = 0.37). There was no difference in pCR rate between those that had surgery <4 weeks and 4-8 weeks (OR 1.01, 95% c. i 0.80-1.28, P = 0.93). CONCLUSION: This meta-analysis shows that the optimum timing of surgery post completion of NACT is 4-8 weeks as it is associated with increased OS and DFS.

Combined TRAM flap with latissimus dorsi myocutaneous flap for reconstruction of a large breast post-radiation induced necrosis.

Radiation therapy is a critical component of breast cancer management following breast-conserving surgery. Post-radiation sequelae are greater in women with larger breasts, given the need for higher doses and dosing heterogeneity. The goal of breast reconstruction post-mastectomy is to improve the quality of life and add no more health risk. The optimal reconstruction should make the patient feel as natural as possible. Reconstruction of a large-sized breast with aesthetically satisfactory outcome poses a challenge to the breast surgeon. The breast of most Egyptian women is of a large volume with variable degrees of ptosis, thus it is difficult to reconstruct such a large-ptotic breast using an implant. We describe the successful reconstruction of a large-sized breast after radiation-induced necrosis using a combined transverse myocutaneous rectus abdominis flap and latissimus dorsi myocutaneous flap reconstruction. The combined use of both flaps offered a more natural breast reconstruction and avoided the use of any implants.

Squamous cell carcinoma of the heel with free latissimus dorsi myocutaneous flap reconstruction: case report and technical note.

Squamous cell carcinoma (SCC) is the second most common skin cancer; however, it is relatively rare on the foot. Wide excision of SCC is the recommended surgical treatment. The extent of the excision may involve resection of muscles and bone in cases of deep lesions. The functional and anatomic properties and lack of sufficient locally available tissues make the reconstruction of post-oncosurgical defects of the foot a challenging process. Heel reconstruction poses the biggest challenge due to the unique weight-bearing requirements. We present a case of a Marjolin's ulcer on the heel in a 62-year-old woman complicating a chronic non-healing wound. The heel defect was reconstructed with a free latissimus dorsi myocutaneous flap with delayed secondary closure. The outcome was successful both functionally and cosmetically. No further procedures were needed.

Advanced rectal cancer in a long-term Hartmann's pouch: a forgotten organ revisited.

Hartmann's procedure is widely performed as a first-stage operation in cases of left colon emergencies when a one stage management is judged to be unsafe. Forty per cent of patients with Hartmann's procedure never get their stoma reversed, ending with a permanent stoma. The distal excluded Hartmann's pouch is usually forgotten compared to the proximal functioning colon. A 70-year-old man with Hartmann's procedure carried out previously for complicated diverticular disease presented with bleeding per rectum. Invasive adenocarcinoma was confirmed on histology. Subsequent staging revealed a locally advanced rectal cancer. The tumour progressed despite a course of neoadjuvant chemoradiation. The general condition of the patient deteriorated with development of renal failure. The patient died a few weeks later. By reporting this case, we are revisiting the long forgotten Hartmann's pouch to highlight the potential pathologies in the distal stump and to emphasise that a distal stump should not be forgotten even in asymptomatic patients.

Langer's arch: a rare anomaly affects axillary lymphadenectomy.

Langer's arch is the best-known anatomic variant of definite surgical implication in the region of the axilla. This rare anomaly is a muscular slip extending from the latissimus dorsi (LD) muscle to the tendons, muscles or fasciae around the superior part of the humerus. In this report, we present a rare case of left axillary arch. During modified radical mastectomy for breast cancer, we encountered an abnormal muscle slip crossing the axilla from the LD muscle to the posterior surface of the pectoralis major muscle anterior to the neurovascular structures. Preoperative knowledge is essential to identify such unusual anomaly and avoid potential complications both intra- and postoperatively.

Rotation flap to cover a large defect on the dorsum of the hand.

The unique requirements of soft tissue coverage of the hand offer a challenge for the surgeon dealing with such defects. Local excision of such lesions may end in a defect that is not amenable to primary closure. Management of such defects requires the application of a graft or flap. We describe the application of a rotation flap for closure of a large defect on the dorsum of the hand following excision of a keratoacanthoma. The rotation flap offers repair with local skin of similar colour, texture and thickness. The end results were excellent both functionally and cosmetically.

Sigmoid volvulus during pregnancy: A rare non-obstetric complication. Report of a case and review of the literature.

INTRODUCTION: Sigmoid volvulus is a rare cause of intestinal obstruction during pregnancy associated with high maternal and foetal mortality. Effective management represents a challenge due to delayed presentation, obstructive symptoms regarded as pregnancy-related and hesitation in using radiological evaluation. PRESENTATION OF CASE: We report a case of a lady, pregnant for 26 weeks and with a 5 day history of abdominal pain and constipation. She underwent concomitant caesarean section and laparotomy for intestinal obstruction. Intra-operatively, the sigmoid colon was extensively dilated and gangrenous. The ischemic colon was resected and a Hartmann's procedure was performed. A preterm male child was delivered and admitted to neonatal intensive care. The post operative course was uneventful and the patient was discharged home on the 9th post-operative day. Six months later she underwent an uneventful reversal of the Hartmann's procedure. DISCUSSION: Sigmoid volvulus is the most common cause of bowel obstruction during pregnancy, accounting for up to 44% of reported cases. We have reviewed the available literature on this topic and present another case managed at our institution. CONCLUSION: Diagnosis of sigmoid volvulus in pregnancy is a challenge, but a delay in diagnosis increases the rates of feto-maternal mortality. A high incidence of clinical suspicion and timely surgical intervention are the key to a favourable outcome.

Obstructive eosinophilic gastroenteritis in a patient with rheumatoid arthritis.

Eosinophilic gastroenteritis (EG) is a rare disease characterised by abnormal eosinophilic infiltration of the gastrointestinal tract. We describe a case of EG presenting as an intestinal obstruction in a patient with rheumatoid arthritis (RA). A 54-year-old man with RA presented to the emergency department with abdominal pain and vomiting. On examination, his abdomen was distended and tender. Laboratory data showed leucocytosis with raised inflammatory markers and without eosinophilia. CT revealed dilated small bowel loops, with a couple of loops forming a mass and abscess formation. Emergency laparotomy was performed with segmental resection of the ileum and side-to-side anastomosis. Histology confirmed the diagnosis of EG. The patient recovered well and was asymptomatic at the time of writing this report.

Left Amyand's hernia: An unexpected finding during inguinal hernia surgery.

INTRODUCTION: Amyand's hernia is a rare finding of the appendix inside an inguinal hernia sac with classically estimated incidence of 1%. Most cases are found intra-operatively during right-sided inguinal hernia repair. PRESENTATION OF CASE: We are reporting a very rare case of left-sided Amyand's hernia. An 81 year-old man with long standing left inguinal hernia was referred to our surgical assessment unit with tender irreducible left inguinal hernia. He was vitally stable with no clinical signs of intestinal obstruction. A diagnosis of irreducible left inguinal hernia without obstruction was made. Exploration of the hernia sac revealed the presence of non-inflamed appendix, caecum and terminal ileum. The contents were reduced and a mesh repair was performed with satisfactorily outcome. DISCUSSION: The surgical management of Amyand's hernia involves appendectomy of inflamed appendix through the inguinal incision together with hernia repair. Prophylactic appendectomy is not recommended by most authors except in young patients. CONCLUSION: There are less than 20 cases reported in the literature describing left-sided Amyand's hernia. Awareness of such very unusual condition may help surgeons to be prepared for appropriate management of a very usual procedure as inguinal hernia repair.