Increasing the incidence of drain-free day-case mastectomies with the use of a fibrin tissue sealant; data from a single surgical center in the United Kingdom.

Day-case mastectomy surgery provides benefits to both patients and hospitals. Key barriers are the use of a drain and the risk of postoperative seroma formation. We introduced the use of a tissue sealant (Artiss) into the surgical site (post-mastectomy without immediate reconstruction and postaxillary clearance) and evaluated its effect on our practice, particularly day-case rates. A prospective audit of 177 patients who underwent a simple mastectomy with or without axillary surgery, or axillary node clearance with or without breast-conserving surgery was conducted at a single surgical center in the UK between November 2015 and November 2016. Artiss was used in all operations and, where appropriate, the drain was omitted to facilitate day-case surgery. The clinical outcomes were compared between patients undergoing different operations and duration of hospital stay. There was no statistically significant difference between day-case patients and inpatients in seroma aspiration rates (24.5% and 21.7%, respectively; P = 0.381) or other complications (22.4% and 16.1%, respectively; P = 0.106). The day-case mastectomy rate increased from 3.9% in the first quarter to 45.5% in the final quarter, which was a significant increase reaching well beyond the national target. The use of Artiss enabled us to increase the drain-free day-case surgery rates over a 1-year period, exceeding the 30% target recommended by the British Association of Day Surgery. We did not observe any increase in patient morbidity, and the change was cost-effective. We have now implemented the routine use of Artiss in women undergoing simple mastectomy with or without axillary surgery and stand-alone axillary node clearances as part of enhanced recovery clinical pathways.

Is mode of presentation of B3 breast core biopsies (screen-detected or symptomatic) a distinguishing factor in the final histopathologic result or risk of diagnosis of malignancy?

BACKGROUND: The relation between histopathologic subclassification and mode of patient presentation (with a screen-detected vs. symptomatic lesion) with an abnormality in the breast core biopsy classified as having uncertain malignant potential (B3) has not been previously examined. We compared the histopathologic subclassification of these lesions and the frequency of malignancy in screen-detected and symptomatic patient groups. METHODS: All B3 core biopsies from one breast unit at the Royal Berkshire Hospital over a 5-year period (2006-2010) were analyzed (n = 131). After dividing the B3 biopsies into screen-detected and symptomatic groups, the National Health Service Breast Screening Programme histopathologic subclassification was used to further divide the groups into six subtypes. After surgery, a final diagnosis of invasive or in situ carcinoma was also noted. RESULTS: B3 classification comprised 3.8 % (131/3,440) of all core biopsies during that time period. There were 78 specimens from symptomatic (59 %) and 53 from screen-detected (41 %) patients. There was no statistically significant difference between papillary and fibroepithelial diagnoses between the two groups (47 vs. 42 %, p = 0.59, NS). There was no difference between the groups for atypia, lobular neoplasia, or sclerosing lesions (49 vs. 51 %, p = 0.8, NS). Cancer was found in 20 % of the symptomatic patients and in 17 % of the screen-detected group (p = 0.65, NS). CONCLUSIONS: Mode of patient presentation (with a screen-detected or symptomatic lesion) was not a distinguishing factor for breast histopathologic subclassification or for the final cancer diagnosis in patients whose breast core biopsy was classified as B3.

Three fatal cases of squamous cell carcinoma arising in chronic perineal hidradenitis suppurativa.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic, inflammatory and suppurative disorder of skin bearing apocrine glands. The most severe complication is squamous cell carcinoma (SCC) and we here present three cases, all of which proved fatal, and review the past 40 years of published cases. PATIENTS AND METHODS: Three advanced cases of SCC arising in chronic HS have been referred for reconstructive surgery over the past 8 years. Another 28 cases published over the past 40 years were identified using a Medline search (search items in combination: hidradenitis, squamous, carcinoma). RESULTS: The male:female ratio was 4:1, most (61%) were perineal or buttock. We found no reports of SCC arising in axillary disease. The symptomatic history of HS prior to SCC diagnosis ranged from 3-50 years with a mean of 25 years. Age at diagnosis of SCC ranged from 27-71 years, and 15 patients (48%) died within 2 years of SCC diagnosis. CONCLUSIONS: We advocate that hidradenitis suppurativa arising in extra-axillary sites is a pre-malignant condition, and should not be treated conservatively; curative resection is the mainstay of management.

Tube pedicle flap in the management of a Grade III C lower limb injury.

Salvage of a Grade III C lower limb injury is a challenging problem. Apart from microsurgical revascularisation, they frequently need soft tissue coverage procedures. Due to the magnitude of the injury, local flaps from adjacent tissues may not be available and microsurgical free flaps are the flaps of choice. We present an instance where the defect in the middle third of a revascularised leg was covered by a tube pedicle flap raised from the groin and transferred, with the wrist as the carrier. This was chosen because of the below knee amputation on the opposite side combined with long segment circumferential loss of skin in the affected extremity and paucity of vein graft sources. Thus the reconstruction of a limb which was saved by microsurgery was completed by tube pedicle flap. In exceptional circumstances 'old' techniques are still useful.