Advanced breast conservation and partial breast reconstruction - a review of current available options for oncoplastic breast surgery.

Breast cancer is the most common cancer affecting one in three women with new cancer diagnosis in England. Breast-conserving surgery is the primary surgical option in a vast majority of these patients. Use of oncoplastic techniques in breast conservation surgery has significantly improved the aesthetic outcomes without compromising the oncological safety of cancer resections. Oncoplastic breast-conserving surgery (OPBCS) has transformed the specialty with a paradigm shift in ideology and the recognition that aesthetic and oncological resections are synonymous when planning surgical intervention for patients with breast cancer. The two main options for OPBCS are therapeutic mammoplasty and partial beast reconstruction using pedicle-based flaps. This review aims to highlight key concepts in OPBCS demonstrating an overview of these surgical techniques, their safety, outcomes and the emergence of extreme oncoplastic breast surgery.

Prophylactic antibiotic use in acellular dermal matrix-assisted implant-based breast reconstruction.

BACKGROUND: Prophylactic antibiotics are used in acellular dermal matrix-assisted implant-based breast reconstructions. However, there are no universally accepted guidelines regarding the best regimen. This retrospective, multicentre study was designed to compare the different prophylactic antibiotic regimens in these patients in three hospitals across two NHS trusts over a five-year period. METHODS: Case notes and electronic records were reviewed for all patients undergoing acellular dermal matrix-assisted implant-based breast reconstructions between January 2010 and December 2014. Prophylactic antibiotic regimens, duration of use, wound infection, implant loss, seroma and therapeutic antibiotic use was recorded. Patients were divided into groups based on prophylactic antibiotic regimen and actual duration of use. Intergroup analysis was performed using Stata 13.0. Implant loss due to infection was the primary outcome measure. RESULTS: A total of 105 patients had 122 breast reconstructions performed over the study period. Four prophylactic antibiotic regimens were identified: single dose (n = 20), three doses (n = 17), antibiotics for five-seven days (n = 51) and antibiotics until drains removed (n = 32). There was no statistically significant difference (p > 0.05) between the various regimens in implant loss, wound infection, therapeutic antibiotic prescription or seroma rates. Based on the actual duration of prophylactic antibiotics usage, three groups were identified: prophylactic antibiotics given for one day (n = 26), antibiotics for up to one week (n = 76) and for more than one week (n = 13). Again, no statistically significant difference was observed in the groups for any outcome measure. CONCLUSION: The study demonstrated no difference in outcomes between different prophylactic antibiotic regimens in acellular dermal matrix-assisted implant-based breast reconstructions.

Mid-term bariatric surgery outcomes for obese patients: does weight matter?

INTRODUCTION: Studies have attempted to identify prognostic indicators for successful outcomes following bariatric surgery for obesity. The aim of this study was to determine whether the degree of obesity affects outcomes in patients who are morbidly obese (basal metabolic index, BMI, 40-49.9 kg/m2), super-obese (BMI 50-59.9 kg/m2) and super-super-obese (BMI greater than 60 kg/m2) undergoing restrictive or malabsorptive bypass procedures. MATERIAL AND METHODS: Retrospective analysis of a prospectively maintained database was undertaken to include all consecutive laparoscopic adjustable gastric bands (LAGB), laparoscopic sleeve gastrectomies (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures since 2010. Patients with at least two years of follow-up were included. At each visit, the patient's weight, BMI, excess weight loss and comorbidity status were recorded. RESULTS: A total of 353 patients (75% women) were included in the analysis; 65 (18.4%) underwent LAGB; 70 (19.8%) LSG and 218 (61.8%) LRYGB. At presentation, the median BMI for the morbidly obese sub-group was 47.2 kg/m2 for LAGB, 46.4 kg/m2 for LSG and 46.6 kg/m2 for LRYGB (P = 0.625); for the super-obese sub-group it was 53.2 kg/m2 for LAGB, 52.9 kg/m2 for LSG and 52.4 kg/m2 for LRYGB (P = 0.481); and for the super-super-obese sub-group 66.9 kg/m2 for (LAGB, 66.7 kg/m2 for LSG and 61.5 kg/m2 for LRYGB (P = 0.169). Percentage of excess weight loss at the end of two years was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB (median 68.5% and 69.5%, respectively; P < 0.001) than in the sub-groups undergoing LAGB and LSG. This was also reflected in the reduction of BMI achieved with bypass in the two sub-groups (P < 0.001). Complete diabetes remission was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB treatment (P < 0.05). Sleep apnoea, asthma and exercise tolerance had significantly improved in the super-morbidly obese undergoing LRYGB (P < 0.05). There was no significant difference between the three treatment groups in remission of hypertension; dyslipidaemia; gastro-oesophageal reflux disease and depression in all three BMI sub-groups. CONCLUSION: The mid-term results for weight loss and resolution of obesity-related comorbidities is best achieved in super-obese patients undergoing LRYGB, without any significant increase in complications with this procedure as compared with LAGB and LSG.