Diagnostic accuracy of tactile imaging in selecting patients with palpable breast abnormalities: a prospective comparative study.

Unnecessary referrals of patients with breast lumps represent a significant issue, since only a few patients actually have lumps when examined by a breast specialist. Tactile imaging (TI) is a novel modality in breast diagnostics armamentarium. The aim of this study was to assess TI's diagnostic performance and compare it to clinical breast examination (CBE). This is a prospective, blinded, comparative study of 276 consecutive patients. All patients underwent conventional imaging and tissue sampling if either a radiological or a palpable abnormality was present. Sensitivity, specificity and positive and negative predictive values for CBE and TI were calculated. Radiological findings and final diagnosis based on histology and/or cytology were used as reference standards. Receiver operator characteristic (ROC) curve analysis was also performed for each method. Sensitivity and specificity of TI in detecting radiologically proven abnormalities were 85.5 % and 35 %, respectively. CBE's sensitivity was 80.3 % and specificity 76 %. In detecting a histopathological entity according to histology/cytology, sensitivity was 88.2 % for TI and 81.6 % for CBE. Specificity was 38.5 % and 85.7 % for TI and CBE, respectively. These results suggest a trend towards higher sensitivity of TI compared to CBE but significantly lower specificity. Subgroup analysis revealed superior sensitivity of TI in detecting a histological entity in pre-menopausal women. However, CBE's overall performance was superior compared to TI's according to ROC curve analysis. Although further research is necessary, the use of TI by the primary care physician as a selection tool for referring patients to a breast specialist should be considered especially in pre-menopausal women.

Comparison of skin-sparing mastectomy versus non-skin-sparing mastectomy for breast cancer: a meta-analysis of observational studies.

OBJECTIVES: To evaluate differences in outcomes of breast cancer patients undergoing either conventional mastectomy without reconstruction (NSSM) or skin-sparing mastectomy (SSM) with immediate reconstruction. DATA SOURCES: All comparative studies published between 1997 and 2009 were used to evaluate local recurrence and distant relapse in the 2 study groups. REVIEW METHODS: Meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, was carried out to evaluate the robustness of the pooled estimates and assess the between-study heterogeneity. RESULTS: Nine studies, comprising of 3739 patients (1104 SSM and 2635 NSSM) were included in the analysis. There were no significant differences in the disease stage or the proportion of invasive cancers between groups (73.9% vs. 83.8%, P = 0.65). There was no significant difference in local recurrence between the SSM versus NSSM groups (7 studies, 3436 patients, 6.2% vs. 4.0%, odds ratio = 1.25, 95% CI: 0.81-1.94) and there was no significant heterogeneity between the studies. The SSM group had a lower proportion of distant relapses compared with the NSSM group (5 studies, 2122 patients, 10.0% vs. 12.7%, odds ratio = 0.67, 95% CI: 0.48-0.94) but this should be interpreted with caution since the grade of the tumors was not adequately reported in the studies considered. CONCLUSIONS: Our results suggest that in breast cancer patients, SSM was not significantly different from NSSM, in terms of rates of local recurrence. As no randomized control trial has addressed this question to date, the present meta-analysis reports the best evidence on the subject.

Diagnosis and surgical management of spontaneous hepatic rupture associated with HELLP syndrome.

Spontaneous hepatic rupture with hemoperitoneum is an uncommon but devastating complication of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Although the syndrome has been considered a variant of preeclampsia/eclampsia, its pathogenesis is not completely understood. Hepatic rupture increases the perinatal and maternal morbidity and mortality. This report describes 3 cases of extensive spontaneous hepatic rupture in pregnant women with HELLP syndrome. Early diagnosis and adequate tertiary management of this rare but life-threatening condition reduce the high maternal and newborn mortality.

Damage control surgery in the abdomen: an approach for the management of severe injured patients.

Damage control is well established as a potentially life-saving procedure in a few selected critically injured patients. In these patients the 'lethal triad' of hypothermia, acidosis, and coagulopathy is presented as a vicious cycle that often can not be interrupted and which marks the limit of the patient's ability to cope with the physiological consequences of injury. The principles of damage control have led to improved survival and to stopped bleeding until the physiologic derangement has been restored and the patient could undergo a prolong operation for definitive repair. Although morbidity is remaining high, it is acceptable if it comes in exchange for improved survival. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. The purpose of this article is to review the physiology of the components of the 'lethal triad', the indication and principles of abdominal damage control of trauma patients, the reoperation time, and the pathophysiology of abdominal compartment syndrome.

Laparoscopic cholecystectomy: a safe approach for management of acute cholecystitis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy (LC) is increasingly being used as an appropriate early treatment in patients with cholecystitis. This study evaluated the safety, effectiveness, and complications of LC in all cases of acute cholecystitis. METHODS: A retrospective study involved the patients who underwent LC for acute cholecystitis within 72 hours of admission. The preoperative diagnosis was based on clinical, laboratory, and echographic examinations, while the final diagnosis was confirmed by histopathological examination of the excised gallbladder. RESULTS: We identified 184 patients with acute cholecystitis. Intraoperative cholangiography (IOC) was not performed. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 62 patients (33.7%), and postoperative ERCP in 13 patients (7.1%). Conversion to open cholecystectomy was necessary in 19 patients (10.3%); 16 patients for severe inflammation and adhesions and 3 patients because of uncontrolled bleeding. The mean operative time was 68 minutes. No deaths occurred. The overall complication rate was 6% with 3 postoperative bile leakages and 2 nonbilious subhepatic collections. The mean postoperative hospital stay was 2.8 days. CONCLUSIONS: LC is a safe, effective procedure for the early management of patients with acute cholecystitis. LC can be safely performed without routine IOC when ERCP is performed preoperatively on the basis of specific indications. Meticulous dissection and good exposure of Calot's triangle may prevent bile duct injuries.

Operative and nonoperative management of blunt hepatic trauma in adults: a single-center report.

BACKGROUND/PURPOSE: Liver trauma, especially that as result of road traffic accidents, still remains a complicated problem in severely injured patients. The aim of this study was to extract useful conclusions from the management in order to improve the final outcome of such patients. METHODS: Details for 86 patients with blunt hepatic trauma who were examined and treated in our department during a 6-year period were analyzed. We retrospectively reviewed the severity of liver injury, associated injuries, treatment, and outcome. RESULTS: Forty-nine liver injuries (57%) were of low severity (grades I and II), while 37 (43%) were of high severity (grades III, IV, and V). Liver trauma with associated injury of other organs was noted in 62 (72.1%) patients. Forty-three (50%) patients underwent an exploratory laparotomy within the first 24 h of admission. Thirty-five (71.4%) of the 49 patients with low-grade hepatic injuries were managed conservatively; no mortality occurred. Six (14%) of forty-three patients with liver trauma initially considered for conservative management required surgery due to hemodynamic instability. Five (13.5%) of 37 patients who were finally managed nonoperatively required adjunctive treatment for biloma, hematoma, or biliary leakage; no mortality occurred. The overall mortality rate was 9.3%; mortality rates of 5.8% and 3.5% were due to liver injuries and concomitant injuries, respectively. CONCLUSIONS: Severe hepatic injuries require surgical intervention due to hemodynamic instability. Low-grade injuries can be managed nonoperatively with excellent results, while patients with hepatic trauma with associated organ injuries require surgery, because they continue to have significantly higher mortality.

Surgical techniques and treatment for hepatic hydatid cysts.

PURPOSE: Hepatic hydatid cysts (HHCs) are a parasitic infestation caused by several species of Echinococcus. We examined the clinical features of HHCs and evaluated the results of various surgical procedures. METHODS: One hundred and sixty-nine patients aged between 17 and 84 years underwent surgery for HHCs within a 12-year period. We recorded the demographic data, location of the cysts, surgical procedures used, morbidity, recurrences, and hospital stay. RESULTS: Most (90.5%) of the patients presented with symptoms, but 16 (9.5%) patients reported no symptoms. The most common symptom was abdominal pain. The overall number of cysts was 216 HHCs and 9 concomitant hydatid cysts in other abdominal organs. The surgical treatments consisted of hepatic resection in 8 (4.7%) patients, cystostomy with drainage in 43 (25.5%), cystostomy with capitonnage in 22 (13%), cystostomy with omentoplasty in 72 (42.6%), and cystectomy in 24 (14.2%). Splenectomy or nephrectomy was also performed in nine patients. Postoperative complications developed in 36 (21.3%) patients, and three suffered recurrences. The postoperative mortality rate was 1.2%. Postoperative complications were more frequent after cystostomy with capitonnage than after cystostomy with omentoplasty (P < 0.001) or cystectomy (P = 0.0037). The additional procedures prolonged the hospital stay. CONCLUSIONS: Current surgical techniques combined with antiscolicidal therapy using albendazole are effective and safe treatments for HHCs, associated with low morbidity, mortality, and recurrence rates.

Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy.

BACKGROUND AND AIMS: Incidental parathyroidectomy is a complication of thyroid surgery. The aim of this report is to explore the incidence, risk factors, and clinical relevance of inadvertent parathyroidectomy during thyroidectomy. MATERIALS AND METHODS: Patients who underwent thyroidectomy between January 1998 and June 2005 were evaluated. Pathology reports were reviewed for the presence of parathyroid tissue in the thyroidectomy specimens. Information regarding diagnosis, operative details, and postoperative hypocalcemia were collected. RESULTS: Three hundred and fifteen thyroid procedures were performed: 163 total thyroidectomies, 124 near-total thyroidectomies, and 28 lobectomies. The findings were benign in 240 and malignant in 75 cases. Incidental parathyroidectomy was found in 68 (21.6%) cases: 58 were benign and 10 were malignant. One and two parathyroids were accidentally removed in 46 and 22 patients, respectively. Parathyroid tissue was found in intrathyroidal (33%) and extracapsular (27%) sites. Total/near-total thyroidectomy was not associated with increased risk of incidental parathyroidectomy (P=0.646), and there was no association of inadvertent parathyroidectomy with postoperative hypocalcemia (P=0.859). Thyroid malignancy was associated with decreased incidence of incidental parathyroidectomy (P=0.047). CONCLUSION: Inadvertent parathyroidectomy, although not uncommon, is not associated with postoperative hypocalcemia. The type of surgical procedure does not increase the risk of incidental parathyroidectomy, while thyroid malignancy may reduce the incidence of inadvertent parathyroidectomy.

Surgical treatment of hepatic haemangiomas: a 15-year experience.

BACKGROUND: Hepatic haemangiomas are congenital vascular malformations. They are the most common benign tumours of the liver and are often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy and rapid growth are the mandatory surgical indications. We present our experience over the last 15 years with the surgical management of 15 liver haemangiomas to clarify the safety and effectiveness of this treatment. METHODS: There were 15 patients with hepatic haemangiomas who were surgically treated from 1990 to 2004. Indications for the operation were spontaneous or traumatic rupture, consumption coagulopathy, rapid growth, abdominal pain and uncertain diagnosis. Four of these lesions were located on the left lobe, nine on the right lobe; one lesion was located on the left and the right lobes and one on segments VII and VIII. Methods for diagnosis included ultrasonography, computed tomography scan, magnetic resonance imaging and selective hepatic arteriography or combinations of more than one technique. RESULTS: The procedures included five right-extended lobectomies, five right lobectomies, one left-extended lobectomy, two left lobectomies and two segmental resections. There was no death. The postoperative morbidity was minimal and was mainly correlated to two subdiaphragmatic collections, one intra-abdominal collection and one wound infection. The postoperative hospital stay was 12.7 days (range, 10-19 days). During the follow-up period, there was no recurrence. CONCLUSION: The resection of the hepatic haemangioma is safe. The indications for resection, however, should be carefully analysed before embarking on such a major operation.

Successful endovascular repair of ruptured abdominal aortic aneurysm in a renal transplant recipient.

A renal transplant recipient presented in the early post-transplantation period with rupture of an abdominal aortic aneurysm. The high mortality rate of the surgical repair of ruptured aneurysm in addition to the concern of preserving the renal graft prompted us to seek alternative approaches, such as repairing the aneurysm by means of endovascular techniques. The ruptured aneurysm was confirmed by performing computed tomography and digital angiography and thereafter was successfully repaired by endovascular stenting technique (Talent stent-graft), which seems to be a safe and effective method of preserving a renal graft.