Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy?

BACKGROUND: Percutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established. STUDY DESIGN: AC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores. RESULTS: The groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV (P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity (P = .6) although mortality was significantly higher in group 1 (P = .02). CONCLUSIONS: PC seems of little benefit and ought to be left for those very old patients with surgical contraindication.

Treatment of symptomatic macromastia in a breast unit.

BACKGROUND: Patients suffering from symptomatic macromastia are usually underserved, as they have to put up with very long waiting lists and are usually selected under restrictive criteria. The Oncoplastic Breast Surgery subspeciality requires a cross-specialty training, which is difficult, in particular, for trainees who have a background in general surgery, and not easily available. The introduction of reduction mammaplasty into a Breast Cancer Unit as treatment for symptomatic macromastia could have a synergic effect, making the scarce therapeutic offer at present available to these patients, who are usually treated in Plastic Departments, somewhat larger, and accelerating the uptake of oncoplastic training as a whole and, specifically, the oncoplastic breast conserving procedures based on the reduction mammaplasty techniques such as displacement conservative techniques and onco-therapeutic mammaplasty. This is a retrospective study analyzing the outcome of reduction mammaplasty for symptomatic macromastia in our Breast Cancer Unit. METHODS: A cohort study of 56 patients who underwent bilateral reduction mammaplasty at our Breast Unit between 2005 and 2009 were evaluated; morbidity and patient satisfaction were considered as end points. Data were collected by reviewing medical records and interviewing patients. RESULTS: Eight patients (14.28%) presented complications in the early postoperative period, two of them being reoperated on. The physical symptoms disappeared or significantly improved in 88% of patients and the degree of satisfaction with the care process and with the overall outcome were really high. CONCLUSION: Our experience of the introduction of reduction mammaplasty in our Breast Cancer Unit has given good results, enabling us to learn the use of different reduction mammaplasty techniques using several pedicles which made it possible to perform oncoplastic breast conserving surgery. In our opinion, this management policy could bring clear advantages both to patients (large-breasted and those with a breast cancer) and surgeons.

Surgery of cosmetic sequelae after breast-conserving therapy.

Although a considerable number of patients have an unfair cosmetic result after breast-conserving therapy, which correlates with poor psychosocial functioning, surprisingly, really only very few patients undergo surgical correction. The purpose of this article was to report our experience in the surgical treatment of such patients and analyze a special subgroup which required bilateral reduction mammaplasty because of associated symptomatic macromastia and their desire to reduce their breast size. From July 2000 to November 2008, some 23 patients consulted for unsatisfactory cosmetic outcome after breast-conserving therapy, fourteen of them accepting the surgical treatment proposed and these were operated upon. We used the following techniques: reduction mammaplasty of the contralateral breast for symmetrization (9), bilateral reduction mammaplasty (4), one mammaplasty and augmentation of contra-lateral breast and one myocutaneous dorsi flap for surgical correction of ipsilateral breast. One patient had serious complications, having partial necrosis of the areola, fat and breast skin necrosis, and needed reoperation for surgical removal of necrotic tissue. Some factors such as obesity and heavy smoking habits could explain this. We were able to evaluate cosmetic outcome in ten patients; late cosmetic outcome was good in seven patients, fair in two and poor in one. Despite the fact that most patients treated by breast-conserving therapy are satisfied with the fact that they have retained their breasts and minimized an unfair cosmetic outcome, cosmetic evaluation should be introduced as a matter of routine.