Clinical Outcomes of Transaxillary Reverse-Sequence Endoscopic Nipple-Sparing Mastectomy and Direct-to-Implant Prepectoral Breast Reconstruction: A Prospective Study of Initial 68 Procedures.

BACKGROUND: Minimal access breast surgery improves cosmetic outcomes over conventional breast surgery but still faces barriers in becoming standard procedure for breast reconstruction. This report introduces a novel technique of transaxillary reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) followed by direct-to-implant prepectoral breast reconstruction (DTI-PBR) and describes its clinical outcomes. METHODS: This prospective study enrolled patients who underwent R-E-NSM and DTI-PBR from March 2021 to December 2021 at a single institution. Perioperative data, surgical complications, oncologic outcomes, and patient- and surgeon-reported cosmetic results were noted. RESULTS: The 60 patients in this study who underwent 68 R-E-NSM and DTI-PBR had a mean age was 40.4 ± 10.3 years. The average durations of uni- and bilateral operations were 156.5 ± 48.3 min and 191.3 ± 36.1 min, respectively. The overall surgical complication rate was 13.3%, including 10.0% of patients with minor complications and 3.3% of patients with major complications. The study had one case (1.7%) of implant loss and one case (1.7%) of skin flap necrosis treated by reoperation. During the median follow-up period of 24 months, one patient (1.7%) who discontinued chemotherapy for myelosuppression experienced liver metastases 5 months postoperatively, and one patient experienced new-onset contralateral ductal carcinoma in situ 24 months postoperatively. The preoperative and 18-month postoperative Breast-Q scores for satisfaction with breasts, psychosocial well-being, sexual well-being, and chest well-being did not differ significantly, and the Scar-Q was 81.2 ± 14.5 points. The good-to-excellent rate in surgeon-reported cosmetic results reached 90%. CONCLUSIONS: Transaxillary R-E-NSM followed by DTI-PBR is a safe and efficient technique with high cosmetic outcomes and reliable medium-term oncologic results.

Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction.

BACKGROUND: Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prosthetic infection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction. METHODS: A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes. RESULTS: A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy. CONCLUSION: Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Innovative and Highly Efficient Single-Port Endoscopic Nipple-/Skin-Sparing Mastectomy and Dual-Plane Direct-to-Implant Breast Reconstruction: A Prospective Study from a Single Institution.

BACKGROUND: The difficulty in creating and maintaining a stable workspace of the breast makes endoscopic nipple-/skin-spring mastectomy (E-N/SSM) develop slowly. This study aims to report the preliminary results of a novel endoscopic technique for N/SSM followed by dual-plane direct-to-implant (DP-DTI) breast reconstruction. METHODS: A prospectively maintained database was reviewed that included patients who underwent single-axillary-incision E-N/SSM and DP-DTI breast reconstruction from September 2020 to April 2021 at a single institution by three surgeons. The data were collected prospectively and analyzed to determine the efficacy, feasibility, safety, and esthetic results of the operation, as well as quality of life (QoL). RESULTS: During the study period, a total of 68 E-N/SSM and DP-DTI reconstruction procedures through a single axillary incision were performed in 63 female patients. Among all the procedures, the majority were performed for grade 1-3 ptotic breasts (n =46, 73.0%). During the median follow-up of 26.5 months, the major and minor surgical complication rates were 1.6% (1/63) and 9.5% (6/63), respectively. The cosmetic complication rate was 14.3%. One patient suffered local recurrence 4 months postoperation. The average scores in patient-reported outcomes at 2 years postoperation of satisfaction with breast (66.57), psychosocial well-being (75.93) and sexual well-being (56.29) were not significantly different compared with the baseline, except for physical well-being: chest (69.85). CONCLUSIONS: The proposed procedure for E-N/SSM and DP-DTI breast reconstruction is feasible, time-saving and safe with good outcomes in terms of cosmetic results and QoL and expands the indications of DTI reconstruction to ptotic breasts, making it easier to popularize. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Short-term safety and cosmetic outcomes of endoscopic direct-to-implant breast reconstruction and simultaneous contralateral breast augmentation for breast cancer: a prospective analysis of 33 patients.

BACKGROUND: For patients with small breasts, breast-conserving surgery (BCS) and unilateral nipple-/skin-sparing mastectomy (N/SSM) with breast reconstruction may result in visible breast deformities or asymmetry, and contralateral breast augmentation often require a two-staged operation. We propose a novel endoscopic technique, direct-to-implant breast reconstruction and simultaneous contralateral breast augmentation (DTI-BR-SCBA), and report its short-term safety and cosmetic outcomes. METHODS: In this prospective study, patients with early breast cancer who underwent endoscopic DTI-BR-SCBA between November 2020 and August 2022 were followed for more than 3 months to analysed short-term postoperative safety (complications and oncological safety) and cosmetic outcomes (doctor-assessed results by Ueda scale and patient-reported results by Breast-Q scale). RESULTS: A total of 33 patients, including 30 treated with endoscopic prepectoral DTI-BR-SCBA, 1 with endoscopic dual-plane DTI-BR-SCBA and 2 with endoscopic subpectoral DTI-BR-SCBA, were analysed. The mean age was 39.7 ± 6.7 years. The mean operation time was 165.1 ± 36.1 min. The overall surgical complication rate was 18.2%. All complications were minor, including haemorrhage (3.0%), cured by compression haemostasis, surgical site infection (9.1%), cured by oral antibiotics, and self-healing nipple-areolar complex ischaemia (6.1%). Furthermore, rippling and implant edge visibility occurred in 6.2% of them. The outcome was graded as "Excellent" and "Good" in 87.9% and 12.1% of patients in the doctor cosmetic assessment, respectively, and patient satisfaction with breasts was significantly improved (55.0 ± 9.5 vs. 58.8 ± 7.9, P = 0.046). CONCLUSIONS: The novel endoscopic DTI-BR-SCBA method may be an ideal alternative for patients with small breasts because it can improve cosmetic results with a relatively low complications rate, which makes it worthy of clinical promotion.

Single Axillary Incision Reverse Sequence Endoscopic Nipple-Sparing Mastectomy in the Management of Gynecomastia: Short-Term Cosmetic Outcomes, Surgical Safety, and Learning Curve of the Preliminary 156 Consecutive Procedures from a Prospective Cohort Study.

BACKGROUND: Currently, a standard, optimal surgical procedure is still lacking for gynecomastia. Despite the development of a variety of surgical interventions, these techniques were often limited to patients with Simon I and II. The present study aimed to introduce a novel technique for all types and grades of gynecomastia, and reported the preliminary results. METHODS: Patients who received single axillary incision reverse sequence endoscopic nipple-sparing mastectomy (R-E-NSM) from March 2021 to March 2023 were enrolled at a single institution. The data from 3-month follow-up cut-off were collected prospectively and analyzed to determine the short-term esthetic and safety results of this technique, as well as the learning curve. RESULTS: A total of 159 single axillary incision reverse sequence endoscopic nipple-sparing mastectomy procedures were performed in 81 gynecomastia patients. Among these 81 patients, 7 patients (8.6%) were classified as Simon grade I, 29 patients (35.8%) as grade IIa, 24 patients (29.6%) as grade IIb, and 21 patients (25.9%) as grade III. In the patient-reported cosmetic results, the overall satisfaction score was 8.4 ± 1.4. A total of 74.1% of patients were highly satisfied, and 25.9% were satisfied. The overall complication rate was 10.1%, and only 1 patient had a major complication. According to the cumulative sum plot analysis, approximately 12 cases were needed for surgeon B and 11 cases for surgeon C to decrease their operation time significantly. CONCLUSIONS: R-E-NSM is safe and effective for all Simon grade gynecomastia patients, with excellent cosmetic results and a short learning curve. However, a long-term follow-up assessment is still needed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Three-Pedicle Reduction Mammaplasty Technique in the Treatment of Greater Breast Hypertrophy Patients With or Without Breast Cancer: Surgical and Patient-reported outcomes.

BACKGROUND: Reduction mammoplasty (RM) is an important procedure in the management of symptomatic greater breast hypertrophy with or without early-stage breast cancer. We aim to introduce a new procedure: the three-pedicle reduction mammaplasty technique. METHODS: A prospectively maintained database was reviewed, and two prospectively registered clinical studies were included of all breast hypertrophy patients with or without breast cancer who underwent three-pedicle RM with inverted T incision at West China Hospital or the Fourth People's Hospital of Sichuan Province from 2018 to 2022. Patient demographics, patient-reported cosmetic results, quality of life (QoL), surgical outcomes and complications were assessed. RESULTS: During a median period of 22.5 months, 101 reduction mammaplasties were performed (Mage= 35.80; MBMI= 27.05). Mean reduction weight was 880.9 g ranging from 423-1630 g per breast. The nipple-to-sternal notch distance (N-SN) at post-operation was significantly shorter than preoperatively (left, 34.51 cm; right, 34.69 cm). Major complications and minor complications were 1.9% (1/52 patients) and 13.5% (7/52 patients), respectively. Multivariate logistic regression analyses showed that BMI > 30 was independent risk factors for a complication. Except for sexual and physical well-being at 1-month post-operation, patients gave a higher score on the BREAST-Q (breast satisfaction, physical well-being, psychosocial well-being) after the operation than before the operation (P<0.001). CONCLUSIONS: The three-pedicle RM technique was demonstrated to be an effective and safe RM procedure for moderate to severe breast hypertrophy patients with or without breast cancer, with the advantages of removing the lesions, reducing hypertrophic breasts and accomplishing mammoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   http://www.springer.com/00266.

What Is the Optimal Strategy for Drain Removal After Mastectomy and Axillary Surgery in Breast Cancer Patients? A Multicenter, Three-Arm Randomized Clinical Trial.

INTRODUCTION: The best strategy for drain removal after mastectomy and axillary surgery in breast cancer patients has remained controversial. We conducted a multicenter, three-arm randomized clinical trial to determine the optimal strategy. METHODS: A total of 187 eligible breast cancer patients who underwent mastectomy and axillary surgery were randomized into 10 mL (n = 62), 20 mL (n = 63), and 30 mL (n = 63) groups for drain removal on the first day when the output decreased to a corresponding volume in 24 h. The drain duration, total drain duration, incidence of seroma, quality of life, outpatient visit times, healthcare costs, and postoperative complications were evaluated. RESULTS: The median axillary drain durations and total drain durations were all significantly different between three groups (both P < 0.001). The incidences of seroma were 31.1%, 38.3%, and 52.1%, and the difference between the 30 mL and 10 mL groups was significant (RR = 2.41). The 20 mL group reported significantly better quality of life (QoL) in terms of physical functioning (PF) at the 2-week (30 mL versus 20 mL, HR:-14.18) and 3-week (20 mL versus 10 mL, HR: 11.65) follow-up and role functioning (RF) at the 2-week follow-up (20 mL versus 10 mL, HR: 18.15). No between-group differences were found in G-QoL, outpatient visits, costs, or complications. CONCLUSIONS: The 20 mL group had a moderate drain duration, total drain duration, and incidence of seroma but a significant advantage over the other two groups in terms of PF and RF, with relatively low outpatient costs and comparable postoperative complication rates. These findings could aid in clinical decision-making regarding drain removal timing (http://www.chictr.org.cn/: ChiCTR2000028729).

Endoscopic Nipple- or Skin-Sparing Mastectomy and Immediate Breast Reconstruction with Endoscopic Harvesting of the Latissimus Dorsi Flap: A Preliminary Experience of an Innovative Technique.

Background: Endoscopic nipple- or skin-sparing mastectomy (E-N/SSM) and endoscopic latissimus dorsi muscle flap (E-LDMF) harvest have been operational difficulties over decades. The aim of this study was to describe the preliminary outcomes of our novel surgical technique, which allows the performance of E-N/SSM and E-LDMF harvest for immediate breast reconstruction (IBR) through a single cosmetic axillary incision for breast cancer patients. Methods: This prospective study included 20 breast cancer patients who underwent E-N/SSM and E-LDMF harvesting through a single axillary incision in our hospital from September 2020 to June 2022. The outcomes were statistically calculated, including patient characteristics, operative data, complication rate, hospital length of stay and costs, and patient-reported outcomes. Results: A total of 20 breast cancer patients underwent our sufficiently mature novel endoscopy technique. The mean LD flap harvest time was 96.5 ± 25.3 min, the mean operation time was 262.6 ± 54.4 min, and the average length of LDMF was 26.9 ± 3.1. During the median follow-up time of 7.5 months, 4 patients developed donor-site seroma. One of them was also complicated by hypopigmentation of the nipple areola, and one of them suffered from breast cellulitis. No bleeding or flap necrosis happened. No tumor recurrence or metastasis was found until the last follow-up. In the BREAST-Q evaluation, although they gave a lower score beginning at 1-month post-operation than preoperatively (P > 0.05, except for physical well-being: chest and physical well-being: back and shoulder, P < 0.01), there was an uptrend at 3 months postoperatively. Because of the hidden and short incision, the mean score of the appearance scale of the SCAR-Q at 3 months post-operation was 74.2 ± 8.8. Conclusions: The novel endoscopy technique, which was first reported to perform lymph node surgery, N/SSM, and LDMF harvesting in an operation for breast cancer patients through a single axillary incision, is associated with a shorter surgery time, lower complication rates, and better patient-reported outcomes.

Video-assisted Transaxillary Nipple-sparing Mastectomy and Immediate Implant-based Breast Reconstruction: A Novel and Promising Method.

BACKGROUND: Although video-assisted breast surgery is gaining popularity, endoscopic reconstruction after mastectomy is still facing lots of problems, bring about that endoscopic method has not yet become a standard procedure for breast cancer reconstruction. Here, we introduce a novel surgical technique of video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction and describe the detailed surgical procedure using this technique. METHODS: Detailed steps of surgical procedure, the patient characteristics and the mean operative time of this new technique were described in this article. All patients were asked to score their satisfaction with their reconstructed breasts preoperatively, 1 month, 3 months, 6 months and 12 months postoperatively using the BREAST-Q. RESULTS: At first, we used our "conventional method" and performed on 10 patients from April 2017 to June 2020; the operative time was 324.80 ± 66.39 minutes. After improving several procedures of the technique, the "optimized method" was performed on 14 cases from July 2020 to November 2020; the operative time decreased to 193.71 ± 28.75 minutes with shortest was 133 minutes; the optimized method was novel and easy to learn and be generalized. Most of the patients were satisfied with the reconstruction results. There was no significant difference between preoperative scores and scores at 3 months, 6 months and 12 months (p = 0.364). Since there is no wound on the breast dome, no obvious postoperative complications were observed except for one patient presented with infection. CONCLUSIONS: This new technique has allowed surgeons to achieve excellent and reproducible outcomes in a single-stage procedure and represents an excellent technique for patients who wish to have a scarless and aesthetically pleasing appearance after mastectomy for breast cancer. This article also highlights the mean operative time (193.71 ± 28.75 minutes) that has been made possible with this new technique. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Adjuvant Chemotherapy Guidance in Young Breast Cancer Patients With Luminal Subtypes and Stage pT1N0.

BACKGROUND: This study evaluated whether young breast cancer patients (≤ 40 y of age) with luminal subtypes and stage pT1N0 can benefit from chemotherapy (CHT). MATERIALS AND METHODS: This study included 688 patients aged ≤ 40 y with luminal subtypes and stage pT1N0 breast cancer. The overall survival and disease-free survival (DFS) rates in the whole cohort and subgroups were compared between patients receiving CHT followed by endocrinotherapy (ET) (CHT→ET group) and those receiving only ET (ET-alone group). RESULTS: Univariate analysis identified that the tumors in the CHT→ET group were more aggressive than those in the ET-alone group. However, the overall survival and DFS rates did not differ significantly between the CHT→ET and ET-alone groups (P = 0.416 and 0.21, respectively), implying that a subgroup of patients could benefit from CHT. Subgroup analysis of DFS rates revealed that patients with human epidermal growth factor receptor 2 overexpression (P = 0.042), histological classification grade 3 (P = 0.030), progesterone receptor ≤ 20% (P = 0.033), and clinical stage T1c (P = 0.038) could benefit from CHT. Further analysis showed that these four risk factors combined predicted whether the patient could benefit from CHT. CONCLUSIONS: Young patients with hormone receptor-positive and stage pT1N0 breast cancer may benefit from CHT only if they exhibit at least two of the following risk factors: progesterone receptor ≤ 20%, human epidermal growth factor receptor 2 overexpression, histological grading 3, or clinical stage T1c.

Criteria derived from serum markers can precisely evaluate axillary status in breast cancer patients.

BACKGROUND: A noninvasive method to confirm the presence of lymph node metastases (LNM) in breast cancer patients is lacking. This study aimed to identify markers from peripheral blood that have diagnostic value in evaluating axillary LNM. METHODS: We tested 26 factors in serum from 57 patients with resectable breast cancer by the Luminex assay. Differences between node-negative and node-positive patients were assessed. The diagnostic value of the factors was determined by further analyses and a validation test. RESULTS: Matrix metalloproteinase-1, hepatocyte growth factor, and chemokine ligand 5 were independent risk factors for LNM. However, receiver operating characteristic analysis showed that these factors alone were not ideal predictors. The LNM score (LNMS), derived from combining these markers, correlated significantly with numbers of positive lymph nodes. Patients with LNMS of 0 had few LNM, axillary lymph node dissection (ALND) could be avoided, and sentinel lymph node biopsy (SLNB) was unnecessary. Very high accuracy was achieved for patients with LNMS of 1 with SLNB using only methylene blue, patients with LNMS of 3 required ALND, and patients with LNMS of 2 needed SLNB using both a radioactive isotope and methylene blue, and ALND. CONCLUSIONS: The LNMS derived from matrix metalloproteinase-1, hepatocyte growth factor, and chemokine ligand 5 serum levels identified the axillary lymph node status with high accuracy. Patients with higher LNMS had a greater probability of LNM.

Octreotide prevents liver failure through upregulating 5'-methylthioadenosine in extended hepatectomized rats.

BACKGROUND & AIMS: Insufficient liver regeneration and hepatocyte injury caused by excessive portal perfusion are considered to be responsible for post-hepatectomy liver failure (PLF) or small-for-size syndrome in living-donor liver transplantation. Somatostatin can decrease portal vein pressure (PVP) but simultaneously inhibits liver regeneration. This interesting paradox motivated us to investigate the outcome of PLF in response to somatostatin treatment. METHODS: Rats receiving extended partial hepatectomy (90% PH) were treated with octreotide, a somatostatin analogue, or placebo. Animal survival, serum parameters and hepatic histology were evaluated. Metabolomic analysis was performed to investigate the effect of octreotide on hepatocyte metabolism. RESULTS: Despite significantly inhibiting early regeneration, octreotide application noticeably improved the hepatic histology, liver function and survival after PH but did not decrease the PVP level. Metabolomic analysis exhibited that octreotide profoundly and exclusively altered the levels of five metabolites that participate in or closely associate with the methionine cycle, a biochemical reaction that uniquely produces S-adenosylmethionine (SAMe), an active methyl residual donor for methyltransferase reactions. Among these metabolites, 5'-methylthioadenosine (MTA), a derivate of SAMe, increased three-fold and was found independently improve the hepatic histology and reduce inflammatory cytokines in hepatectomized rats. CONCLUSIONS: Octreotide exclusively regulates the methionine cycle reaction and augments the MTA level in hepatocytes. MTA prominently protects hepatocytes against shear stress injury and reduces the secondary inflammation, thereby protecting rats from PLF.

Risk factors and criteria predicting early graft loss after adult-to-adult living donor liver transplantation.

BACKGROUND: Because deceased liver donors are scarce, adult-to-adult living donor liver transplantation (LDLT) is considered a suitable alterative. However, LDLT grafts are usually partial, resulting in a higher risk of early graft loss (EGL). The aim of the present study was to identify the risk factors and criteria predicting EGL after LDLT. METHODS: We retrospectively analyzed 178 consecutive adults who underwent LDLT. The recipients were divided into two groups as follows: group I, wherein patients showed graft survival longer than 3 mo after LDLT (n = 164), and group II, wherein graft loss occurred within 3 mo after transplantation (n = 14). RESULTS: Univariate analysis showed various risk factors; however, only the preoperative model for end-stage liver disease score, the presence of obvious pretransplant portal hypertension, and intraoperative blood loss were identified as independent predictors of EGL by multivariate analysis. After LDLT, significant differences were observed between the groups in the fold change in total bilirubin levels over postoperative day (POD) 1 (TBIL-f1) and in the international normalized ratio over POD 1 (INR-f1). The combination of TBIL-f1 and INR-f1 on POD 10 was found to be a strong EGL predictor. Furthermore, a minimum indocyanine green (ICG) clearance rate constant K (m-KICG) <0.100/min after POD 3 was found to be the strongest predictor of EGL (sensitivity, 100%; specificity, 97.2%). CONCLUSIONS: The postoperative m-KICG and combination of TBIL-f1 and INR-f1 on POD 10 were useful predictors of EGL; moreover, m-KICG was superior and is expected to be especially useful for ensuring timely retransplantation.

Risk factors associated with early and late recurrence after curative resection of hepatocellular carcinoma: a single institution's experience with 398 consecutive patients.

BACKGROUND: Surgical resection is an important curative treatment for hepatocellular carcinoma (HCC); however, some patients experience an unexpected recurrence even after hepatectomy. The present study aimed to investigate risk factors and predictive criteria for early and late recurrence of HCC after resection. METHODS: A retrospective analysis of 398 Chinese patients who received curative resection for HCC was conducted. Patients were divided into three groups: without recurrence, early recurrence, and late recurrence. Prognostic factors and predictive criteria for early and late recurrence were statistically analyzed. RESULTS: The cumulative recurrence-free survival rates at 1, 2, 3, 4, and 5 years were 75.5%, 58.2%, 54.1%, 40.5%, and 28.7%, respectively. The distribution of the time to recurrence suggested that recurrence could be divided into early phase (before 2 years; n=164) and late phase (after 2 years; n=83). Cox's multivariate proportional hazard model analysis revealed that multiplicity of tumors (P=0.004) and venous infiltration (P=0.002) were independent risk factors associated with early recurrence. In contrast, indocyanine green retention rate at 15 minutes (P=0.007), serum albumin level (P=0.045), and HBeAg status (P=0.028) proved to be significant independent adverse prognostic factors for late recurrence. Patients with at least 1 of the 2 early recurrence risk factors (multiplicity of tumors ≥ 2 and venous infiltration) or with 2 or more late recurrence risk factors are often susceptible to recurrence (P=1.36e-4 and 1.0e-6, respectively). CONCLUSIONS: Early and late recurrences correlate with different risk factors and predictive criteria. Early recurrence primarily results from intrahepatic metastases, while late recurrence may be multicentric in origin.

Mesohepatectomy versus extended hemihepatectomy for centrally located hepatocellular carcinoma.

BACKGROUND: Extended hemihepatectomy is usually recommended to treat large centrally located hepatocellular carcinoma (HCC). However, the morbidity and mortality are high because of the postoperative liver failure. Mesohepatectomy is seldom used because of its technical complexity. This study aimed to evaluate the short-term and long-term curative effect of mesohepatectomy. METHODS: From January 2002 to September 2008, a total of 198 consecutive patients with centrally located HCC underwent hepatectomy in our department. According to the surgical procedures, they were divided into mesohepatectomy (group M, n=118), extended right hemihepatectomy (group RE, n=47) and extended left hemihepatectomy (group LE, n=33) groups. The surgical techniques, clinical pathological characteristics and outcomes were compared between group M, group RE and group LE. RESULTS: The operative time of group M was significantly longer than that of the other two groups (P<0.05); however the total bilirubin on postoperative day 3 in group M was the lowest among the three groups (P<0.01). In group M, the number of the patients whose resection margin achieving 1 cm was significantly lower than that of the other two groups (P<0.05). The mortality rates in groups M, RE and LE were 2.5%, 8.5% and 3.0%, respectively (P>0.05). The morbidity rate in group M was significantly lower than that in group RE (37.3% vs 55.3%, P=0.034), but not in group LE (37.3% vs 24.2%, P=0.163). The biliary leakage tended to be more common in group M (10.2%, P>0.05). The incidence of postoperative liver failure in group M was significantly lower than that in group RE (1.7% vs 10.6%, P=0.032), but not in group LE (1.7% vs 6.1%, P=0.208). The 1-, 3- and 5-year tumor-free survival rates and the overall survival rates after mesohepatectomy were 53.4%, 30.5% and 16.9% and 67.8%, 45.5% and 28.9%, respectively. CONCLUSIONS: Mesohepatectomy is a safe and effective technique for centrally located HCC patients. Compared with extended right hemihepatectomy, mesohepatectomy can retain residual liver volume to the maximum limit and reduce postoperative liver failure rate. But no significant advantage was found compared mesohepatectomy to extended left hemihepatectomy.

[Past and present of endoscopic surgery and robotic surgery in treatment of breast diseases].

Objective: To review the research progress related to endoscopic surgery and robotic surgery for breast diseases, aiming to provide references for clinical practice. Methods: The recent domestic and international literature on endoscopic surgery and robotic surgery for breast diseases was reviewed, then the challenges in their development, the innovative evolution of endoscopic surgery combined with clinical practice by our team, and its clinical applications were summarized. Results: Traditional endoscopic surgery, despite its advantages such as minimal invasiveness, good cosmetic outcomes, and high patient's satisfaction, has been limited in its development due to specific difficulties in establishing the operative field. Our team innovatively proposed the "reverse sequence method" and the Huaxi Hole 1 theory and methods, cleverly altering the surgical procedure sequence, adding small operative orifices to transform single-port operations into multi-port ones, effectively overcoming the challenges restricting the advancement of endoscopic surgery in the field of breast diseases, thereby enabling further proliferation of endoscopic procedures. In terms of breast endoscopic reconstruction surgery, the parachute patch technique has broadened the indications for reconstruction surgery, benefiting patients with a certain degree of breast ptosis; and the postoperative adjustment concept, through early intervention in the post-reconstruction breast shape, has further refined the reconstruction procedure. Robot-assisted surgery derived from endoscopic surgery theory has further enhanced the precision and stability of surgeries, reducing surgical risks; however, excessive time and economic costs are urgent issues that must be addressed. Conclusion: Through theoretical innovations, endoscopic surgery has been applied in the excision and reconstruction of breast lesions, while robotic surgery shows promising applications in autologous breast reconstruction, especially in the latissimus dorsi reconstruction field. Nevertheless, the lack of high-level large-sample, multi-center randomized controlled clinical trials to confirm its surgical safety, oncological safety, and postoperative cosmetic outcomes is an important direction for future research.

Reverse-sequence endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction: an improvement of conventional minimal access breast surgery.

Background: Our center proposes a new technique that effectively provides space to broaden the surgical field of view and overcomes the limitations of endoscopy-assisted nipple-sparing mastectomy (E-NSM) by changing the dissection sequence and combining it with air inflation. The purpose of this study was to compare the clinical outcomes of the new technique designated "reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with subpectoral breast reconstruction (SBR)" and the conventional E-NSM (C-E-NSM) with SBR. Method: All patients undergoing E-NSM with SBR at our breast center between April 2017 and December 2022 were included in this study. The cohort was divided into the C-E-NSM group and the R-E-NSM group. The operation time, anesthesia time, medical cost, complications, cosmetic outcomes, and oncological safety were compared. Results: Twenty-six and seventy-nine consecutive patients were included in the C-E-NSM and R-E-NSM groups, with average ages of 36.9 ± 7.0 years and 39.7 ± 8.4 years (P=0.128). Patients in the R-E-NSM group had significantly shorter operation time (204.6 ± 59.2 vs. 318.9 ± 75.5 minutes, p<0.001) and anesthesia time (279.4 ± 83.9 vs. 408.9 ± 87.4 minutes, p<0.001) and decreased medical costs [5063.4 (4439.6-6532.3) vs. 6404.2 (5152.5-7981.5), USD, p=0.001] and increase SCAR-Q scores (77.2 ± 17.1 vs. 68.8 ± 8.7, P=0.002) compared to the C-E-NSM group. Although trends increased in both the excellent rate of Ueda scores (53.8% vs. 42.3%, P = 0.144), excellent rate of Harris scores (44.0% vs. 63.1%, P=0.102), and decreased surgical complications (7.6% vs. 19.2%, P = 0.135) were observed in the R-E-NSM group, the differences were not significant. There were no significant differences in oncological outcomes between the two groups. Conclusion: R-E-NSM improves cosmetic outcomes and efficiency of C-E-NSM, reduces medical costs, and has a trend of lower surgical complications while maintaining the safety of oncology. It is a safe and feasible option for oncological procedures that deserves to be promoted and widely adopted in practice.

[Effectiveness comparison of endoscopic removal of injectable Amazingel with/without immediate prepectoral implant-based breast augmentation].

Objective: To explore the surgical technique and preliminary safety and aesthetic results of endoscopic removal of injectable Amazingel with/without immediate prepectoral implant-based breast augmentation for patients. Methods: The clinical data of 25 patients who underwent endoscopic removal of injectable Amazingel with/without immediate prepectoral implant-based breast augmentation between April 2020 and January 2024 and met the selection criteria was retrospective analysed. The patients' age ranged from 33 to 73 years, with a mean of 50.4 years, and the body mass index ranged from 16.8 to 26.6 kg/m 2, with a mean of 21.5 kg/m 2. They were all bilaterally injected with Amazingel, and the time between initial injections and surgery ranged from 17 to 26 years, with a mean of 21.4 years. Early safety was evaluated by the incidence of early postoperative complications, and early aesthetic results were evaluated using Harris scores (including breast shape satisfaction, sensation satisfaction, and elasticity satisfaction) at 3 months after operation. Results: There were 9 cases underwent Amazingel removal (group A) and 16 cases underwent Amazingel removal with immediate prepectoral implant-based breast augmentation (group B). Intraoperative removal of Amazingel ranged from 808 to 1 285 mL, with a mean of 1 050.7 mL; the mass of the capsule removed ranged from 36 to 169 g, with a mean of 103.6 g; and a gross anatomical prosthesis was used with a median size of 345 mL (range, 315-355 mL). The operation time ranged from 95 to 395 minutes, with a mean of 194.2 minutes; and the cost of the procedure ranged from 8000to 91 000 yuan, with a mean of 33 000 yuan. Patients had a median follow-up time of 22.7 months (range, 3.0-48.1 months). There was 1 case of intraoperative skin burn due to the operation of the electric scalpel, which healed naturally after operation without flap necrosis. There was no adverse conditions such as prosthesis outline showing, ripple sign, and capsular contracture during follow-up; a small amount of Amazingel residue was found in 2 patients at 1 year after operation. The Harris score at 3 months after operation was used to evaluate the early aesthetic results, and the breast shape, elasticity, and sensation satisfaction of group A were lower than group B, but the differences between the two groups were not significant ( P>0.05). Conclusion: Endoscopic removal of injectable Amazingel with/without immediate prepectoral implant-based breast augmentation is safe in the early stage with good aesthetic results, and it is also recommended that patients who had the indications for combined immediate breast augmentation after removal to rebuild the breast appearance.