Major chest wall resection for recurrent breast carcinoma.

Local recurrence of breast cancer is a relatively common entity. Occasionally, the management of such recurrences necessitates full-thickness chest wall resection. Although the chance for cure in such circumstances is small, achieving local control remains a desirable goal to maintain comfort and hygiene. This study evaluates the utility and morbidity of full-thickness chest wall resection in the control of symptomatic local recurrence of breast carcinoma. Twelve patients, undergoing such resections, were identified from hospital records. The resections included an average of three ribs (range, two to five) and, in seven cases, part or all of the sternum. A variety of rigid and soft tissue chest wall reconstructive techniques were utilized. Of the 11 patients available for follow-up, ten reported good overall function postoperatively. There were no postoperative deaths and only one patient developed a major complication requiring prolonged hospital stay. The patients spent an average of 6.6 hours in surgery, 14.6 hours intubated, and 20 days in the hospital. There were ten patients available for long-term follow-up. At the time of this study, 70 per cent were still alive, with or without disease, with a mean survival of 27 months (range, 3-71 months). Forty per cent were alive, disease-free, with a mean survival of 36 months (range, 3-71 months). This series demonstrates low morbidity, improved quality of life, and the possibility of long-term, disease-free survival after full-thickness chest wall resection for recurrent breast carcinoma.

Evaluation of anemia caused by hemorrhoidal bleeding.

PURPOSE: Hemorrhoidal bleeding and anemia are two common entities. The purpose of this article is to review the incidence of hemorrhoidal bleeding that causes anemia in a stable population, to describe patients who have hemorrhoidal bleeding that caused anemia, and to define observations regarding the recovery of their anemia. METHOD: This was a retrospective chart review of patients seen at the Mayo Clinic and Olmsted Community Hospital in Rochester, Minnesota, from 1976 through 1990. RESULTS: Incidence of hemorrhoidal bleeding that caused anemia was found to be 0.5 patients per 100,000 population per year in Olmsted County from 1976 to 1990. The mean age of 43 patients studied was 50 (range, 25-72) years. Twenty-seven patients were male, and 16 were female. Ninety-three percent of these patients had grade 2 or 3 internal hemorrhoidal disease. Six had impaired coagulation. The mean hemoglobin concentration before treatment was 9.4 g/dl (+/- 0.97 SD). Of note was the description of hemorrhoidal bleeding that included blood squirting or clots passing in 84 percent of patients for whom a description was available. It was found that recovery from anemia after definitive treatment with hemorrhoidectomy was rapid, with a mean hemoglobin concentration of 12.3 g/dl after two months, and by six months, the mean hemoglobin concentration was 14.1 g/dl. CONCLUSION: It is imperative to evaluate other causes of anemia when presented with hemorrhoidal bleeding with anemia. If no other sources are identified, treatment of the hemorrhoid should be undertaken, and a rapid return of hemoglobin concentration can be expected within two months, and all patients should have a normal hemoglobin by six months. Failure to recover hemoglobin concentration should prompt further or repeated evaluation for other causes of bleeding.

Laparoscopic appendectomy. A comparison with open appendectomy.

PURPOSE: As laparoscopy becomes a greater part of a general surgeon's practice, each new application must be analyzed. The purpose of this article is to report a four-year experience with laparoscopic appendectomy, with special attention to complications. METHODS: All patients undergoing appendectomy by members of the General Surgery Department of Columbia Hospital between December 20, 1990, and December 24, 1994, were included (n = 434). Medical records were reviewed, and data were analyzed using multiple regression analysis, analysis of variance, and Pearson's chi-squared test. RESULTS: The number of post-operative intra-abdominal abscesses following laparoscopic appendectomy tended to be higher; however, this did not reach statistical significance. Conversely, all other complications combined demonstrated a rate of 4.3 percent for laparoscopic procedures and a rate of 8.5 percent for open procedures. Again this tended toward, but did not reach, statistical significance. Advantage in length of stay was approximately two days, with a mean length of stay for patients undergoing laparoscopic appendectomy of 3.3 days, whereas that for open appendectomy was 5.7 days. CONCLUSION: Laparoscopic appendectomy has significant advantages in terms of patient comfort and length of stay, and its overall complication rate seems to be lower than with open procedures; however, its rate of intra-abdominal abscess may actually be higher. Further study is recommended.

Histologic evaluation of rat mammary tumor necrosis by interstitial Nd:YAG laser hyperthermia.

The extent of coagulative necrosis caused by interstitial laser hyperthermia was measured for different quantities of laser energy in a rat mammary tumor model. Continuous wave Nd:YAG laser at a power level of 5 W was focused onto a 600 mu diameter bare tip quartz fiber and placed inside a 19-gauge needle, which allowed the para-axial flow of normal saline at 1 cc/min. A microthermocouple soldered to the outside of the probe continuously provided the interstitial temperature. After the probe was inserted into the tumor, it was withdrawn as laser energy was administered at a rate sufficient to maintain the temperature within 42-45 degrees C. Tumors were excised after 48 hours, fixed in formalin, cut in 3 mm slices, and the coagulated surfaces measured microscopically. Laser fiber transmission loss was 1% per 1,000 J of laser energy and the average time required to coagulate 1 cc of tumor was 2 minutes. There was a statistically significant correlation between the volume of tumor necrosis and the level of laser irradiation (r = 0.71, P less than 0.001). It is concluded that the described technique is an efficient method of tumor coagulation by interstitial laser hyperthermia and proportionally larger volumes of necrosis are created with greater amounts of laser energy.

Incidental cholecystectomy during colorectal surgery.

OBJECTIVE: To assess the risks and benefits of incidental cholecystectomy in patients having colorectal surgery. SUMMARY BACKGROUND DATA: Cholelithiasis is found commonly during abdominal surgery. Previous studies used disparate methods to assess the risks and benefits of incidental cholecystectomy and have reached contradictory conclusions. METHODS: All patients in whom asymptomatic cholelithiasis was noted during colorectal surgery between January 1982 and December 1986 were studied. Operative morbidity and long-term outcome were assessed by chart review and questionnaire. RESULTS: Three hundred five patients were identified, of whom 195 (63.9%) had an incidental cholecystectomy and 110 (36.1%) did not. The two groups were similar in terms of age, sex, primary disease, and associated medical conditions, although fewer emergency procedures, abdominoperineal resections, and Hartmann's procedures were needed in the cholecystectomy group. The overall operative morbidity rate was the same in both groups. The long-term risk for developing small bowel obstruction was also similar. After a median follow-up of 6 years after hospital discharge, biliary pain or cholecystitis developed in 16 patients (14.6%) in the "no cholecystectomy" group, 12 of whom have had cholecystectomy. Two additional patients had cholecystectomy for acute postoperative cholecystitis while still in the hospital. Six more patients have had incidental cholecystectomy at subsequent laparotomies. The cumulative probability of needing cholecystectomy at 2 and 5 years after the initial colorectal operation was 12.1% and 21.6%, respectively. CONCLUSIONS: Incidental cholecystectomy was not associated with increased postoperative morbidity, whereas the long-term risk that previously asymptomatic gallstones would become symptomatic was substantial. Unless there are clear contraindications, patients with asymptomatic gallstones who have colorectal surgery should have concomitant cholecystectomy.