Practical Guidance for Measuring and Reporting Surgical Margins in Vulvar Cancer.

Surgical resection with free surgical margins is the cornerstone of successful primary treatment of vulvar squamous cell carcinoma (VSCC). In general reexcision is recommended when the minimum peripheral surgical margin (MPSM) is <8 mm microscopically. Pathologists are, therefore, required to report the minimum distance from the tumor to the surgical margin. Currently, there are no guidelines on how to make this measurement, as this is often considered straightforward. However, during the 2018 Annual Meeting of the British Association of Gynaecological Pathologists (BAGP), a discussion on this topic revealed a variety of opinions with regard to reporting and method of measuring margin clearance in VSCC specimens. Given the need for uniformity and the lack of guidance in the literature, we initiated an online survey in order to deliver a consensus-based definition of peripheral surgical margins in VSCC resections. The survey included questions and representative diagrams of peripheral margin measurements. In total, 57 pathologists participated in this survey. On the basis of consensus results, we propose to define MPSM in VSCC as the minimum distance from the peripheral edge of the invasive tumor nests toward the inked peripheral surgical margin reported in millimeters. This MPSM measurement should run through tissue and preferably be measured in a straight line. Along with MPSM, other relevant measurements such as depth of invasion or tumor thickness and distance to deep margins should be reported. This manuscript provides guidance to the practicing pathologist in measuring MPSM in VSCC resection specimens, in order to promote uniformity in measuring and reporting.

Comparison of Ultrasoundguided Ilioinguinal Iliohypogastric Nerve Block with Wound Infiltration during Pediatric Herniotomy Surgeries.

BACKGROUND AND AIMS: The purpose of this study was to compare the analgesic efficacy of the ilioinguinal-iliohypogastric nerve block (II/IH) with local wound infiltration in children undergoing herniotomy surgeries. METHODS: After ethics committee approval and informed consent, 100 children aged 6 months-7 years posted for herniotomy surgeries were randomly divided into Group B and Group W. Local wound infiltration was performed in Group W by the surgeon at the time of port placement and the end of the surgery with 0.2 mL.kg-1 of 0.25% bupivacaine. Ipsilateral II/IH was performed in Group B at the end of the surgery, under ultrasonographic guidance with a Sonosite portable ultrasound unit and a linear 5-10 MHz probe with a 22G hypodermic needle, and 0.2 mL.kg-1 of 0.25% bupivacaine was used on each side. The parameters recorded were postoperative hemodynamics, paracetamol and opioid requirements, postoperative pain scores, postoperative nausea vomiting, and the need for rescue analgesia in the first 6 h postoperatively. RESULTS: The median pain scores were significantly lower in the II/IH group than the local wound infiltration group at 10 min (2 [0-2.5] compared to 2 [3-4]; P = 0.011), 30 min (1.5 [0-3] compared to 3 [2-5]; P < 0.001), 1 h (1.5 [0-2] compared to 2 [2-3]; P < 0.001) and 2 h (2 [0-2] compared to 2 [1.5-2.5]; P = 0.010) postoperatively. The need for postoperative opioids and rescue analgesia was also significantly lower in the II/IH group (P < 0.001). CONCLUSION: II/IH is superior to local wound infiltration for postoperative analgesia in pediatric herniotomy surgeries.

A prospective comparative study of local infiltration versus adductor block versus combined use of the two techniques following knee arthroplasty.

BACKGROUND: Pain management after total knee arthroplasty (TKA) is important as acute postoperative pain can affect patient's ability to walk and participate in rehabilitation required for good functional outcome. This is achieved by effective intra-operative and post-operative analgesia to facilitate early recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) are analgesic regimens and commonly used for effective post-operative analgesia after TKA. Our aim was to compare the efficacy and outcomes of these two methods, combined and independently. METHODS: Our study included 120 patients undergoing unilateral TKA, who were randomized into three groups: LIA (Group I), ACB (Group II) and combined LIA + ACB (Group III). Patients were operated by a single surgeon. The outcome was defined by post-operative analgesia achieved by the three techniques (measured by the NPRS) and amount of fentanyl consumed postoperatively. Secondary outcome was evaluated based on postoperative functional outcomes in terms of ability to stand, distance covered, range of motion of knee on the 1st post-operative day, complications and WOMAC (Western Ontario & McMaster Universities Osteoarthritis Index) scores. RESULTS: All patients were available for analysis. Numerical Pain Rating Scale for pain showed significant differences at 24 h between Group I and Group II, with a p value of 0.018 (GroupI was better), significant differences were found at 24 h between Group III and Group II, with p values being 0.023 and 0.004 (GroupIII was better). No significant differences were found between Group I and Group III at 24 h. Total fentanyl consumption was significantly less in Group III than in Group I and Group II, with p value being 0.042 and 0.005, respectively (Group III was better and consumed less fentanyl). No significant differences were found in WOMAC scores between the three groups at baseline, 2 and 6 weeks after operation. CONCLUSION: In patients undergoing TKA, analgesic effect of combined ACB and LIA was superior, as indicated by reduced opioid consumption and no differences in functional outcomes and complications were observed as compared to separate use of the two techniques.

Colistin and polymyxin B: a re-emergence.

One of the greatest achievements of modern medicine is the development of antibiotics against life-threatening infections, but the emergence of multidrug-resistant (MDR) gram negative bacteria has drastically narrowed down the therapeutic options against them. This limitation has led clinicians to reappraise the clinical application of polymyxins, an old class of cationic, cyclic polypeptide antibiotics. Polymyxins are active against selected gram-negative bacteria, including the Acinetobacter species, Pseudomonas aeruginosa, Klebsiella species, and Enterobacter species. In this article, we summarise the chemistry, pharmacokinetics, and pharmacodynamics of polymyxins and the latest understanding of their action against MDR pathogens.

Bone cement implantation syndrome: a report of four cases.

SUMMARY: Cardiovascular collapse following use of methylmethacrylate for lower limb surgeries has been reported. However there are no reports of cement reaction following shoulder arthroplasty. We report series of four patients exhibiting cement reaction. Two of our patients had cardiovascular collapse following cement insertion during hip arthroplasty. Severe hemodynamic derangement and transient hypoxemia was observed during cemented arthroplasty of shoulder and knee respectively. Peripheral vasodilatory effects of the cement monomer, fat and marrow embolism and activation of the clotting cascade in the lungs, all contribute to cement reaction. Early and aggressive resuscitation with use of vasopressors, establishment of invasive hemodynamic monitoring and surgical modifications are the key to prevention of catastrophic outcome.