Neoadjuvant chemotherapy in non-metastatic breast cancer: The surgeon's perspective.

Breast cancer is the most common non-skin cancer in Australia, affecting 1 in 7 women by the age of 85 years. Current management of early breast cancer is becoming increasingly variable and complex. The typical range of treatments include some combination of surgery, chemotherapy and targeted therapy, immunotherapy, radiotherapy, and endocrine therapy. Neoadjuvant chemotherapy (NACT) in carefully selected patients can facilitate increased rates of breast conservation therapy, and when successful, offers improved cosmesis due to less extensive resection of tissue. A neoadjuvant approach also provides biological insight into a patient's tumour, prognostication based on a patient's response to therapy, as well as enabling their treating oncologist to personalise adjuvant strategies based on the presence or absence of residual cancer at surgery. Neoadjuvant chemotherapy has become an integral element in the provision of breast conserving surgery to selected early-stage breast cancer patients. Appreciating the indications and understanding the likely outcomes from NACT in select situations, can result in significant improvements in patient tailored care.

Seven years of preoperative BTA abdominal wall preparation and the Macquarie system for surgical management of complex ventral hernia.

PURPOSE: To assess 7-year outcomes after complex ventral hernia (CVH) repair using pre-operative Botulinum toxin A (BTA) injection and the Macquarie System of management. METHODS: Clinical examination and functional non-contrast abdominal CT scans were used to assess complications and recurrences encountered in a prospective series of 88 consecutive CVH repairs using pre-operative BTA injection (200 or 300 units) between November 2012 and December 2019. Pre-operative progressive pneumoperitoneum (PPP) and/or component separation (CS) were also used in some cases. RESULTS: All hernia defects (mean transverse width 12.9 ± 5.2 cm) were successfully closed using either laparoscopic or laparoscopic-assisted open techniques facilitated by pre-operative BTA injection. The mean pre-operative post-BTA lateral oblique length gain was 4.7 ± 2.2 cm/side (p < 0.001). In 43 patients with defects < 12 cm wide, closure was achieved using BTA-only in 33 (76.7%), BTA + PPP in 2 (4.7%), BTA + CS in 5 (11.6%) and BTA + PPP + CS in 3 (7.0%). In the remaining 45 patients with defects [Formula: see text] 12 cm wide, closure was achieved using BTA-only in 9 (20.0%), BTA + PPP in 11 (24.4%), BTA + CS in 5 (11.1%) and BTA + PPP + CS in 20 (44.4%). There was a significant correlation between increasing defect size and the need for 2 or more CVH closure procedures (χ2 = 25.28, p < 0.0005). There were no BTA complications. Two patients developed midline hernia recurrences. CONCLUSION: Pre-operative BTA injection of the abdominal wall is a safe procedure that facilitates hernia defect closure and reduces the need for CS, especially when defect size is less than 12 cm. BTA may also decrease the rate of hernia recurrence.

Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair.

INTRODUCTION: Repair of complex ventral hernia presents a significant challenge plagued by high morbidity and recurrence. Recent studies have demonstrated significant benefits achievable with preoperative Botulinum Toxin A (BTA) chemical component paralysis to the abdominal wall muscles, facilitating primary closure of complex ventral hernia defects. However, transversus abdominis is known to play an integral role in truncal stability, and its paralysis can result in unwanted physiological changes. This is the first study to report on selective administration of preoperative BTA to internal and external oblique muscles only, thus sparing transversus abdominis from paralysis. METHODS: This is a prospective observational study of 46 patients who underwent either selective two-layer or standard three-layer abdominal wall muscle BTA injection prior to elective laparoscopic ventral hernia repair. Serial abdominal CT imaging was performed to compare defect size and length of the lateral abdominal musculature. RESULTS: 46 patients received preoperative BTA injections (23 in each group). A comparison of gains achieved from chemical component paralysis demonstrated no statistically significant difference between the two groups. Fascial closure was achieved in all cases, with no post-operative sequelae of abdominal hypertension. There are no hernia recurrences to date. CONCLUSION: Preoperative selective muscle chemical component paralysis is an effective technique to counteract the chronic muscle retraction observed in large ventral hernias. Transversus abdominis plays a significant role in truncal and spinal stability, and sparing it from paralysis preserves an important component of abdominal wall physiology and does not detract from the ability to primarily close complex defects.

The macquarie system for comprehensive management of complex ventral hernia.

BACKGROUND: Despite recent advances in the operative management of complex ventral hernia (CVH), significant challenges remain. Closure of large defects can have serious pathophysiological consequences due to chronic contraction and retraction of the lateral abdominal wall muscles. Certain features of CVH make repair technically demanding and time consuming, such as massive fascial defects, unusual hernia locations, involvement of other abdominal wall structures and previous tissue trauma. METHODS: Preoperative assessment with three-dimensional volume rendered CT (3DVR-CT) imaging and an illustrative series of clinical cases is introduced for repair of CVH using laparoscopic approach. RESULTS: CVH presented here include traumatic hernias involving extensive tissue trauma, massive ventral hernias with defects > 20 cm in width, hernias requiring additional procedures such as wiring of ribs, and hernias in difficult locations such as suprapubic and flank hernias. Specific techniques such as individually tailoring mesh and size, transfascial mesh straps fixation and transcutaneous defect closure will be discussed. All hernias in this series have been repaired laparoscopically (Lap) or laparoscopic-open-laparoscopic (LOL) technique with transcutaneous fascial closure. After hernia closure the mesh is placed in either an intra-peritoneal onlay mesh (IPOM) placement or modified Rives-Stoppa technique with pre-peritoneal mesh placement. CONCLUSION: CVH repair requires multidisciplinary planning with management tailored to each patient's clinical and surgical requirements. The surgeon must have a variety of surgical skills and strategies to address the multiple and/or atypical defects that affect these patients.

Laparoscopic repair of complex ventral hernia facilitated by pre-operative chemical component relaxation using Botulinum Toxin A.

PURPOSE: The operative management of complex ventral hernia poses a formidable challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. This study examines the effect of pre-operative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce temporary flaccid paralysis in order to facilitate laparoscopic repair of large complex ventral hernia. METHODS: This is a prospective evaluation of 27 patients from January 2013 to August 2015 who underwent ultrasound guided BTA injections to the lateral abdominal wall muscles prior to elective complex ventral hernia repair. Non-contrast serial CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size and abdominal wall muscle thickness and length. Fascial defects were closed and hernias repaired using laparoscopic or laparoscopic-assisted intra-peritoneal onlay mesh (IPOM) techniques. RESULTS: 27 patients received pre-operative BTA injections which were well tolerated with no complications. Comparison of pre-BTA and post-BTA CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7 cm pre-BTA to 19.9 cm post-BTA (p < 0.0001), with mean unstretched length gain of 4.2 cm/side (range 0-11.7 cm/side). All hernias were surgically reduced and repaired with mesh, with no early recurrences. CONCLUSION: Pre-operative administration of BTA is a safe and effective technique in the pre-operative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes the laterally retracted abdominal muscles and enables laparoscopic closure of large complex ventral hernia.

Quality of Life (QOL) of patients with Gilles de la Tourette's syndrome.

OBJECTIVE: This is the first study to investigate the Quality of Life (QOL) of patients with Gilles de la Tourette's Syndrome (GTS). METHOD: One hundred and three out-patients with GTS completed a semi-structured interview and 90 of these completed questionnaires screening for depression, anxiety and obsessive-compulsive behaviour. QOL was measured with the SF-36 and the Quality of Life Assessment Schedule (QOLAS). RESULTS: Patients with GTS showed significantly worse QOL than a general population sample. They had better QOL than patients with intractable epilepsy as measured by the QOLAS, although the SF-36 showed significant differences on the subscales Role Limitation due to physical problems and Social Functioning only. Factors influencing QOL domains were employment status, tic severity, obsessive-compulsive behaviour, anxiety and depression. CONCLUSION: QOL is impaired in patients with GTS. Measurement of QOL could be used alongside conventional measurements to assess benefit of treatment. We recommend the QOLAS and SF-36 be used.

Quality of life pre and post epilepsy surgery.

The aim of this work was to assess the health-related quality of life (HRQL) of patients pre and post surgical treatment for epilepsy. A total of 145 patients were interviewed during their pre-surgical assessment on the telemetry unit, Queen Square. The HRQL assessment comprised the quality of life assessment schedule (QOLAS), the EuroQol EQ-5D and the epilepsy surgery inventory (ESI-55). A total of 40 patients were followed up, of which 22 had undergone surgery and achieved 75% or greater reduction in seizures. The QOLAS scores for the patients who achieved 75% or greater seizure reduction post-op were significantly lower (i.e. improved HRQL) compared to baseline. The descriptive data suggest that the EQ-5D may not be capturing all of the QOL issues of relevance to patients with chronic, intractable epilepsy and the EQ-5D may not be valid for this group. Most patients queried the visual analogue scale (VAS) which asks for an overall rating of the respondent's self-perceived health. The most frequent comments, from 42% of patients, was that 'health' did not include their epilepsy. Despite this, the group whose seizures were reduced had significantly higher VAS scores at follow-up. We can conclude that the VAS is sensitive to clinical change. The baseline EQ-5D utility and follow-up scores were compared. There were no significant changes in QOL scores for either group. The patients who achieved 75% or greater reduction in seizures post-op scored significantly higher (i.e. better QOL) on 2/3 composite scores of the ESI-55 at follow-up. The QOLAS, the EQ-5D VAS and the ESI-55 were sensitive to clinically defined outcome. The results for the EQ-5D profile and the EQ-5D utility suggest that the EQ-5D is not a valid and responsive instrument for use in patients with intractable epilepsy.