Different types of implants for reconstructive breast surgery.

BACKGROUND: Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast. OBJECTIVES: To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS: Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies. AUTHORS' CONCLUSIONS: Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.

Linking factors to incisional hernia following pancreatic surgery: a 14-year retrospective analysis.

BACKGROUND: Incisional hernias (IH) are a significant postoperative complication with profound implications for patient morbidity and healthcare costs. The relationship between IH and perioperative factors in pancreatic surgery, with particular attention to preoperative biliary stents and pancreatic fistulas requires further exploration. METHODS: This retrospective observational study examined adult patients who underwent open pancreatic surgeries via midline incision at a high-volume tertiary hepatopancreatobiliary center from January 2008 to December 2021. The study focused on IH incidence and associated risk factors, with particular attention to preoperative biliary stents and pancreatic fistulas. RESULTS: In a cohort of 620 individuals undergoing pancreatic surgery, 351 had open surgery with at least one-year follow-up. Within a median follow-up of 794 days (IQR 1694-537), the overall incidence of IH was 17.38%. The highest frequency of IH was observed among patients who had a Pancreaticoduodenectomy (PD). Significant predictors for the development of IH within the entire study population in a multivariable analysis included perioperative biliary stenting (OR 2.05; 95% CI 1.06-3.96; p = 0.03), increased age at diagnosis (OR 2.05; 95% CI 1.06-3.96; p = 0.01), and BMI (OR 1.08; 95% CI 1.01-1.15; p = 0.01). In the subset of patients who underwent Pancreaticoduodenectomy (PD), although the presence of biliary stents was associated with a heightened occurrence of SSIs, it did not demonstrate a direct correlation with an increased incidence of incisional hernias (IH). The development of pancreatic fistulas did not show a significant correlation with IH in either the Distal Pancreatectomy with Splenectomy (DPS) or the PD patient groups. CONCLUSIONS: The study underscores a notable association between biliary stent placement and increased IH risk after PD, mediated by elevated SSI incidence. Pancreatic fistulas were not directly correlated with IH in the studied cohorts. Further research is necessary to validate these findings and guide clinical practice.

Breast cancer surgery in elderly patients: postoperative complications and survival.

AIMS AND BACKGROUND: Old age is associated with comorbidity and decreased functioning which influences treatment decisions in elderly breast cancer patients. The purpose of this study was to identify risk factors for complications after breast cancer surgery in elderly patients, and to assess mortality in patients with postoperative complications. METHODS: We retrospectively considered all female patients aged 65 years and older with invasive and in situ breast cancer who were diagnosed and treated between 1997 and 2012 in the Department of General and Geriatric Surgery of the University of Naples "Federico II". RESULTS AND CONCLUSION: 449 patients received surgery, of whom 18,2% (n = 82) developed one or more postoperative complications. The odds ratio of having postoperative complications show an increase with age, reaching statistical significance only for patients older than 85 [OR 5,75 (95% confidence interval 2,38-14,04); p < 0,001]. Number of concomitant diseases [OR 2,51 (95% CI 1,17 - 5,45); p = 0,01 for 3 or more concomitant diseases] and polypharmacy [OR 16,7 (95% CI 9,12 - 30,58); p < 0,0001) are associated to an increased risk of postoperative complications. Overall survival was worse in patients with postoperative complications [HR 2,06 (95% CI 1,52-2,70), p < 0,001]. This increased risk of mortality is probably due to geriatric parameters such as comorbidity or poor physical function, more than to higher complication rates.

Undertreatment of breast cancer in the elderly.

AIMS: The effect of undertreatment with adjuvant hormonal therapy, chemotherapy or radiation was studied in elderly women with breast cancer. METHODS: A prospectively maintained database was used to identify women undergoing potentially curative surgery between 1997 and 2011. The presentation, pathologic findings, treatment and outcomes of 449 women over 65 were compared to the findings in 1049 younger patients. Moreover, conventionally treated and undertreated elderly patients were identified and their characteristics and outcomes were compared. RESULTS: Both young and old patients presented most frequently with mammographic findings, but older patients presented more frequently with mammographic masses while younger patients presented more frequently with mammographic calcifications. Cancers of older patients were signicantly more favorable than cancers in younger patients with more infiltrating lobular, fewer ductal carcinoma in situ and more frequently estrogen receptor positive and fewer were poorly differentiated. Elderly patients had less axillary surgery, less adjuvant radiation therapy and more hormonal therapy. Fourty-six percent of the 449 elderly patients were undertreated by conventional criteria. Undertreated patients were more frequently in situ, better differentiated, smaller, and more often estrogen receptor positive. Forty-four percent of the undertreated patients died during follow-up without disease recurrence. CONCLUSIONS: Despite undertreatment, local and distant disease-free survival was comparable to patients who were not undertreated.

Severe Ketoacidosis After One Anastomosis Gastric Bypass Surgery.

BACKGROUND Bariatric surgeries, such as one anastomosis gastric bypass (OAGB), has become a popular treatment option for managing obesity and associated comorbidities, including type-2 diabetes mellitus (T2DM). However, severe starvation ketoacidosis is a rare but potentially life-threatening complication that can occur postoperatively in patients with T2DM. Despite the increasing prevalence of these surgeries, the existing literature has limited information on severe starvation ketoacidosis as a postoperative complication. It is essential for healthcare professionals to be aware of this complication, its manifestations, and risk factors to ensure patient safety and improve outcomes. Therefore, this article aims to address the current gap in the literature and provide a comprehensive review of severe starvation ketoacidosis as a postoperative complication of bariatric surgeries, specifically OAGB, and its associated risk factors and manifestations. CASE REPORT A 38-year-old man with severe obesity and inadequately managed T2DM underwent OAGB surgery. On the second postoperative day, the patient experienced severe starvation ketoacidosis, exhibiting symptoms such as drowsiness, fatigue, weakness, and Kussmaul breathing. Blood gas analysis indicated significant metabolic acidosis. He was quickly transferred to the Intensive Care Unit (ICU) and given intravenous glucose and insulin therapy. Following this intervention, he showed rapid recovery and normalization of blood gases. He was discharged 6 days after surgery with normal clinical examination results and laboratory indices. CONCLUSIONS This case study emphasizes the significance of thorough preoperative glycemic control, comprehensive perioperative multidisciplinary management, and close postoperative monitoring for diabetic patients undergoing metabolic and bariatric surgeries. By implementing these strategies, healthcare professionals can reduce the risk of complications such as hypoglycemia or hyperglycemia/diabetic ketoacidosis (DKA) and enhance patient outcomes. The case also highlights the need for continuous education and training for healthcare providers to identify and manage such rare complications effectively.

Shouldice technique versus other open techniques for inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most frequent operation in general surgery. There are several techniques: the Shouldice technique is sometimes considered the best method but different techniques are used as the "gold standard" for open hernia repair. Outcome measures, such as recurrence rates, complications and length of post operative stay, vary considerably among the various techniques. OBJECTIVES: To evaluate the efficacy and safety of the Shouldice technique compared to other non-laparoscopic techniques for hernia repair. SEARCH METHODS: We searched MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL), April 2008 and updated the searches September 2011, for relevant randomised controlled trials. SELECTION CRITERIA: Any randomised or quasi-randomised controlled trials (RCT) on the treatment of primary inguinal hernia in adults were considered for inclusion. DATA COLLECTION AND ANALYSIS: All abstracts identified by the search strategies were assessed by two independent researchers to exclude studies that did not meet the inclusion criteria. The full publications of all possibly relevant abstracts were obtained and formally assessed. Missing or updated informations was sought by contacting the authors. MAIN RESULTS: Sixteen trials contributed to this review. A total of 2566 hernias were analysed in the Shouldice group with 1121 mesh and 1608 non-mesh techniques. The recurrence rate with Shouldice techniques was higher than mesh techniques (OR 3.80, 95% CI 1.99 to 7.26) but lower than non-mesh techniques (OR 0.62, 95% CI 0.45 to 0.85). There were no significant differences in chronic pain, complications and post-operative stay. Female were nearly 3% of included patients. AUTHORS' CONCLUSIONS: Shouldice herniorrhaphy is the best non-mesh technique in terms of recurrence, though it is more time consuming and needs a slightly longer post-operative hospital stay. The use of mesh is associated with a lower rate of recurrence. The quality of included studies, assessed with jaded scale, were low. Patients have similar characteristic in the treatment and control group but seems more healthy than in general population, this features may affect the dimension of effect in particularly recurrence rate could be higher in general population. Lost to follow-up were similar in the treatment and control group but the reasons were often not reported. The length of follow-up vary broadly among the studies from 1 year to 13.7 year.

"Bulb-like" sign: Small bowel closed loop obstruction in incarcerated Spigelian hernia.

A Spigelian hernia is a rare hernia, making up approximately 0.1% of all abdominal wall hernias. This hernia goes through a defect in the Spigelian fascia which is the part of the transversus abdominis aponeurosis lateral to the rectus muscle, often at the level of the arcuate line, where the fascia is widest and weakest. Clinical diagnosis is difficult in patients without obvious abdominal mass but imaging can be a valuable adjunct in diagnosis. We report the case of a 64-year-old male who presented to our hospital with small bowel obstruction secondary to an incarcerated Spigelian hernia who was pre-operatively diagnosed with ultrasound and computed tomography. At ultrasound and computed tomography a closed loop obstruction in a Spigelian Hernia was detected, resembling on both imaging modalities a "bulb-like" appearance.

Shouldice technique versus other open techniques for inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most frequent operation in general surgery. There are several techniques: the Shouldice technique is sometimes considered the best method but different techniques are used as the "gold standard" for open hernia repair. Outcome measures, such as recurrence rates, complications and length of post operative stay, vary considerably among the various techniques. OBJECTIVES: To evaluate the efficacy and safety of the Shouldice technique compared to other non-laparoscopic techniques for hernia repair. SEARCH STRATEGY: We searched MEDLINE, EMBASE, and The Cochrane Central Register of Controlled Trials (CENTRAL), April 2008, for relevant randomised controlled trials. SELECTION CRITERIA: Any randomised or quasi-randomised controlled trials (RCT) on the treatment of primary inguinal hernia in adults were considered for inclusion. DATA COLLECTION AND ANALYSIS: All abstracts identified by the search strategies were assessed by two independent researchers to exclude studies that did not meet the inclusion criteria. The full publications of all possibly relevant abstracts were obtained and formally assessed. Missing or updated informations was sought by contacting the authors. MAIN RESULTS: Sixteen trials contributed to this review. A total of 2566 hernias were analysed in the Shouldice group with 1121 mesh and 1608 non-mesh techniques. The recurrence rate with Shouldice techniques was higher than mesh techniques (OR 3.80, 95% CI 1.99 to 7.26) but lower than non-mesh techniques (OR 0.62, 95% CI 0.45 to 0.85). There were no significant differences in chronic pain, complications and post-operative stay. Female were nearly 3% of included patients. AUTHORS' CONCLUSIONS: Shouldice herniorrhaphy is the best non-mesh technique in terms of recurrence, though it is more time consuming and needs a slightly longer post-operative hospital stay. The use of mesh is associated with a lower rate of recurrence. The quality of included studies, assessed with jaded scale, were low. Patients have similar characteristic in the treatment and control group but seems more healthy than in general population, this features may affect the dimension of effect in particularly recurrence rate could be higher in general population. Lost to follow-up were similar in the treatment and control group but the reasons were often not reported. The length of follow-up vary broadly among the studies from 1 year to 13.7 year.

Role of Mitomycin C in Preventing Capsular Contracture in Implant-Based Reconstructive Breast Surgery: A Randomized Controlled Trial.

BACKGROUND: Capsular contracture represents the most frequent complication after implant-based breast reconstruction. An experimental study on mice demonstrated that capsule formation around breast implants is considerably diminished after topical application of mitomycin C. The authors conducted a randomized controlled clinical trial investigating the efficacy of mitomycin C in reducing capsular contracture rates following implant-based breast reconstruction after mastectomy for breast cancer. METHODS: The authors randomized all women older than 18 years scheduled for the second stage of an implant-based breast reconstruction after mastectomy for breast cancer at the National Cancer Institute in Milan from October of 2005 to February of 2010 to receive or not receive the topical application of mitomycin C during surgery. The authors assessed capsular contracture, major postoperative complications, and aesthetic outcome. RESULTS: The authors randomized 322 patients to receive mitomycin C or not at the second stage of implant-based breast reconstruction. One hundred sixty-two patients were allocated to the mitomycin C group and 160 patients were allocated to the control group. The relative risk of capsular contracture in the mitomycin C group was 0.92 (95 percent CI, 0.60 to 1.41). Major complications leading to reintervention, oncologic outcomes, and aesthetic outcomes were comparable between the two groups. CONCLUSIONS: This is the first trial reporting data about the use of mitomycin C in breast reconstructive surgery in a clinical setting. Mitomycin C seems not to significantly affect capsular contracture rate and severity following implant-based reconstructive breast surgery at the tested doses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Assessment of bacterial infection in chronic wounds in the elderly: biopsy versus VERSAJET.

AIM: The aim of this study was to evaluate the hydro-surgery VERSAJET system as a suitable alternative to the traditional invasive tissue sampling technique in detecting bacteria and their load in chronic wounds in the elderly. MATERIALS AND METHODS: To investigate and evaluate bacterial incidence and load in chronic wounds, we simultaneously performed on 19 affected patients a deep tissue biopsy and tissue collections by the VERSAJET hydro-surgical system. After local cleaning and anesthesia, a deep biopsy was performed with a punch of 3-4 mm in diameter. Subsequently, three tissue samples were collected by the VERSAJET system: one from the first washing in order to investigate the superficial contamination; one from the second washing to investigate deep tissue infection investigation and one from the third washing as a control procedure. After treatment, all tissue samples were cultured in vitro for diagnostic and micro-biological assessment. RESULTS: Nineteen patients with chronic wounds of the lower limbs were enrolled from February 2010 to May 2013. Concordance between deep tissue biopsy cultures and tissue cultures collected by the VERSAJET system was examined. The deep tissue biopsy cultures showed complete concordance with the VERSAJET as follows: 2 patients (11%) for the first washing sample; 10 patients (53%) for the second washing sample; 4 patients (21%) for the third washing sample. However, with reference to only aerobic isolated strains, the concordance of the VERSAJET second washing samples cultures with a biopsy of the deep tissue cultures was very high (84%) and fairly high (63%) in the anaerobic isolated strains. The second VERSAJET washing sample cultures seem to have the highest concordance with the biopsy of the deep tissue cultures. CONCLUSIONS: Tissue biopsy remains the leading technique for detecting bacteria and their load in chronic wounds. However, this study shows that the hydro-surgery VERSAJET system is sufficiently effective in detecting bacteria and their load in chronic wounds and can be a potential alternative to a biopsy. In particular, the second washing sample culture showed the best correlation with the deep tissue biopsy culture. However, further studies are needed in order to modify techniques of tissue collection in the VERSAJET system before drawing any conclusions.

Axillary masses in a woman with a history of breast cancer: dermatopathic lymphadenopathy.

The presence of axillary enlarged lymph nodes in the follow-up of a woman with a history of breast cancer should always be thoroughly indagated. Dermatopathic lymphadenopathy presents a specific pathologic pattern found within the lymph nodes and is usually associated with cutaneous rashes. Patients with various skin conditions can develop regional lymphadenopathy, which can result in the asymptomatic enlargement of the lymph nodes, especially in the inguinal, axillary and cervical regions. Dermatopathic lymphadenopathy should be considered in the differential diagnosis also in patients with minimal cutaneous findings. Dermatopathic lymphadenopathy is a benign process and management of these patients consists in simple clinical, mammographic and ultrasonographic follow-up.

Increase of mastectomy rates after preoperative MRI in women with breast cancer is not influenced by patients age.

Preoperative magnetic resonance imaging (MRI) is increasingly used for staging women with breast cancer, including screening for occult ipsilateral or contralateral cancer. If breast-conserving surgery is planned, a MRI examination should be performed in all ages women with suspected breast cancer, especially those exhibiting dense or heterogeneously dense breast parenchyma, for which the sensitivity of both ultrasonography and mammography is low. MRI staging causes more extensive breast surgery in a significative proportion of women by identifying additional cancer. If the ability to find additional occult cancer is the true value of MRI, this is not influenced by patients' ages. For this reason, preoperative MRI should be counseled to all women with breast cancer by clinicians, independently from the age, as the age alone does not preclude additional findings.

Intraoperative radiation therapy with electrons in breast cancer conservative treatment: our experience.

Radiotherapy plays a central role in the local control of breast cancer following conservative surgery, representing the standard treatment for patients undergoing quadrantectomy or lumpectomy and consisting in 5 or 6 weeks of treatment with a total dose of 45-50 Gy. In the last ten years new trends in radiation therapy have been developing with a new planning of duration and extension of breast tissue to irradiate. Moreover some authors presented the idea of combining the use of intraoperatory radiotherapy with the partial breast irradiation, with the aim of irradiate the breast in a single session during breast conserving surgery. From September 2009 to July 2010 we prospectively enrolled 13 patients to undergo electron beam intraoperative radiotherapy after breast conservative treatment for early breast cancer. At a mean follow-up of 46 months no local recurrences have been described and no patients presented distant metastasis or died for any cause. 6 patients (46.2%) presented complications, as fibrosis and liponecrosis. Our results suggest that electron beam intraoperative radiotherapy in the conservative treatment of breast cancer could be considered a suitable option for low risk patients, even if our sample is very small and we need longer follow-up to draw conclusive results.

Laparoscopic surgery for colon cancer.

Colon cancer is a major problem in Western countries and complete surgical resection is the main treatment. Since its introduction the laparoscopic approach has been used to achieve bowel resection with a better postoperative course and better aesthetic outcomes. Initial concerns about the radicality of the resection and the oncologic outcomes have been overcome in the last decade. All over the world large trials have been conducted to compare the laparoscopic approach and the traditional laparotomic one. A review of literature has been conducted to find evidence about this issue, revealing 24 relevant trials. The laparoscopic approach showed short-term benefits without compromising oncological safety. However intraoperative complication rates during laparoscopic colon resections seem to be increased, mainly due to the increased rate of intraoperative bowel injury. This finding confirms a great need for training and a wide learning curve for the surgeon. Our review supports the continued use of laparoscopic surgery in patients with colon cancer.

[History of haemostasis in surgery]. / Storia dell'emostasi in chirurgia.

Haemostasis is an essential act in surgical procedures. Technical, physical and chemical devices' improvement in haemostasis is joined to the historical evolution of surgery. In ancient times haemostasis had also a magic and religious value. Simple but effective manoeuvres developed by medicine-men and barber-surgeons are used to control bleeding. Often their original intuitions anticipated scientific discoveries. Ancient haemostatic instruments and the way to use them represent the heritage of old and famous surgeons; some of these procedures are still used in operating rooms.