Necesidad de vaciamiento axilar en el cáncer de mama. Rigor en los métodos predictivos / Need for axillary lymph node dissection in breast cancer. Rigour in predictive methods

Introduccción: El objetivo es describir la validez diagnóstica y la seguridad de los métodos empleados en nuestro entorno para obviar el vaciamiento axilar en el tratamiento quirúrgico primario de mama en estadio inicial tras determinación de macrometástasis en el ganglio centinela. Métodos: Estudio observacional retrospectivo multicéntrico aprobado por el Comité de Ética. Determinación de sensibilidad, especificidad, valor predictivo positivo y negativo de los métodos: OSNA (punto de corte a 15.000 copias de ARN), score Tenon 5 (punto de corte en 5), perfil de alto riesgo (si no cumple T1G2RH+ HER-), criterios ACOSOG Z-11 y resultado de ganglio secundario. Se incluyó a pacientes con cáncer de mama dirigidas a tratamiento quirúrgico primario; tamaño T1-T2 y axila clínica y radiológicamente negativa; con resultado de ganglio centinela positivo para macrometástasis. Resultados: Se incluyó a 279 pacientes con macrometástasis en el ganglio centinela, de los cuales resultaron 69 (24,4%) linfadenectomías positivas. Los resultados de sensibilidad, especificidad, valor predictivo positivo y negativo fueron: OSNA (100%, 17%, 32%, 100%); Tenon 5 (91%, 34%, 31%, 92%); alto riesgo (82%, 32%, 28%, 85%), ACOSOG Z-11 (30%, 97%, 75%, 84%); ganglio secundario (86%, 76%, 55%, 94%). Conclusiones: El método más seguro, score Tenon 5, solo evitaría un tercio de linfadenectomías negativas. Un perfil de riesgo no ofrecería suficiente seguridad. La propuesta del grupo ACOSOG Z-11 sería el método menos seguro. La cuantificación de la macrometástasis por método OSNA no conseguiría validez diagnóstica. El análisis del ganglio secundario, siendo el método menos aplicado, sería el más válido, con mejor sensibilidad y especificidad conjunta. En nuestra valoración, ninguno de los métodos estudiados resultaría suficientemente riguroso pues no obtendrían resultados óptimos para permitir obviar la linfadenectomía

Introduction: The aim of this study was to describe the diagnostic validity and safety of the most commonly used methods to avoid axillary lymph node dissection (ALND) in the primary surgical treatment of initial-stage breast cancer after determination of sentinel node macrometastases. Methods: This multicenter, retrospective observational study was approved by the ethics committee and assessed the sensitivity, specificity, positive and negative predictive value of the following methods: OSNA (cut-off point of 15,000 RNA copies), Tenon 5 score (cut-off point 5), HIGH risk profile (RH+ HER-), ACOSOG Z-11 criteria and second-tier sentinel node outcome. We included patients with breast cancer undergoing primary surgical treatment, with T1-T2 tumours, clinically and radiologically negative axillae, and sentinel node macrometastases. Results: We included 279 patients, of whom 69 (24.4%) had a positive ALND. The results of sensitivity, specificity, positive predictive value and negative predictive value were as follows: OSNA (100%, 17%, 32%, 100%); Tenon 5 (91%, 34%, 31%, 92%); HIGH (82%, 32%, 28%, 85%), ACOSOG Z-11 (30%, 97%, 75%, 84%); SECOND (86%, 76%, 59%, 94%). Conclusions: The most accurate method, the Tenon score, would only avoid one-third of negative lymphadenectomies. Relying on a risk profile would not provide enough safety. The proposal of the ACOSOG Z-11 group was the least safe method. Quantification of macrometastases by OSNA would not be a valid diagnostic method. Second-tier sentinel node analysis, the least applied method, seems the most accurate, with the best sensitivity and specificity.In our analysis, none of the methods would be sufficiently rigorous to safely allow avoidance of ALND

Resultados de las 100 primeras colecistectomías por puerto único en un hospital de segundo nivel / Results of the first 100 single port laparoscopic cholecystectomies in a secondary care hospital

INTRODUCCIÓN: Aunque los resultados de la colecistectomía laparoscópica estándar son excelentes, se continúa intentando minimizar el número de puertos con el objeto de disminuir el dolor postoperatorio, conseguir una recuperación más temprana y mejorar el resultado estético del paciente. El objetivo de este estudio es presentar los resultados de los primeros 100 casos de colecistectomía por puerto único practicados en un hospital de segundo nivel. MATERIAL Y MÉTODOS: Estudio prospectivo, observacional, unicéntrico. Se intervino a 100 pacientes entre enero de 2010 y abril de 2012. CRITERIOS DE INCLUSIÓN: pacientes mayores de 16 años con colelitiasis sintomática operados por colecistectomía simple mediante incisión umbilical única. Criterios de exclusión: antecedentes de colecistitis aguda, colangiopancreatografía retrógrada endoscópica, pancreatitis o sospecha de coledocolitiasis, IMC > 35 y laparotomías previas. Se estudiaron distintas variables epidemiológicas, quirúrgicas y de seguridad. RESULTADOS: La edad media de los pacientes fue de 39,89 ± 11,5 años. El tiempo quirúrgico medio fue de 67,94 ± 25,5 min. Presentaron complicaciones postoperatorias 2 pacientes: seroma y fuga biliar. En 2 casos fue necesaria la utilización de trocar accesorio. La estancia media fue de 1,13 ± 0,8 días. El 35% de los pacientes fueron tratados en régimen de cirugía mayor ambulatoria. Todos los pacientes se mostraron muy satisfechos con el resultado estético. CONCLUSIONES: La colecistectomía mediante incisión umbilical única es una buena técnica cuando se utiliza en casos seleccionados y por cirujanos expertos. Puede facilitar la práctica de la colecistectomía en régimen ambulatorio. No se han presentado complicaciones graves. El índice de satisfacción estética es muy elevado

INTRODUCTION: Despite the excellent results obtained with standard laparoscopic cholecystectomy, the efforts for minimizing the ports needed to reduce postoperative pain, for a quicker recovery and to improve the patient's cosmetics continue. The aim of this study is to report the results of the first 100 cases of single port laparoscopic cholecystectomy performed in a secondary care hospital. MATERIAL AND METHODS: Prospective, observational and unicentric study including 100 patients between January 2010 and April 2012. Inclusion criteria: symptomatic cholelythiasis patients over 16 years of age on whom a single port laparoscopic cholecystectomy was performed. Exclusion criteria: history of acute cholecystitis, pancreatitis or suspected choledocholithiasis, Endoscopic retrograde cholangiopancreatography, BMI > 35 and previous laparotomies. We studied epidemiological, surgical and safety variables. RESULTS: The mean patient age was 39.89 ± 11.5 years. The mean time of the surgical procedure was 67.94 ± 25.5 min. There were 2 cases of postoperative complications: a non-infected seroma and a biliar leak. In 2 cases the use of an accessory trocar was needed. The mean hospital stay was 1.13 ± 0.8 days. A total of 35% patients were included in the major ambulatory surgery program. The overall patient satisfaction survey rating showed a high level of cosmetic satisfaction in 100% of patients. CONCLUSIONS: Single port laparoscopic cholecystectomy is a good technique when performed in selected cases by expert surgeons. It is feasible to include the single port laparoscopic cholecystectomy in a major ambulatory surgery program. We have not had serious complications. There is a high cosmetic satisfaction index with this technique

Results of the first 100 single port laparoscopic cholecystectomies in a secondary care hospital.

INTRODUCTION: Despite the excellent results obtained with standard laparoscopic cholecystectomy, the efforts for minimizing the ports needed to reduce postoperative pain, for a quicker recovery and to improve the patient's cosmetics continue. The aim of this study is to report the results of the first 100 cases of single port laparoscopic cholecystectomy performed in a secondary care hospital. MATERIAL AND METHODS: Prospective, observational and unicentric study including 100 patients between January 2010 and April 2012. INCLUSION CRITERIA: symptomatic cholelythiasis patients over 16-years of age on whom a single port laparoscopic cholecystectomy was performed. EXCLUSION CRITERIA: history of acute cholecystitis, pancreatitis or suspected choledocholithiasis, Endoscopic retrograde cholangiopancreatography, BMI>35 and previous laparotomies. We studied epidemiological, surgical and safety variables. RESULTS: The mean patient age was 39,89 ± 11,5 years. The mean time of the surgical procedure was 67,94 ± 25,5 min. There were 2 cases of postoperative complications. A non-infected seroma and a biliar leak. In 2 cases the use of an accessory trocar was needed. The mean hospital stay was 1,13 ± 0,8 days. A total of 35% patients were included in the major ambulatory surgery programme.The overall patient satisfaction survey rating showed a high level of cosmetic satisfaction in 100% of patients. CONCLUSIONS: Single port laparoscopic cholecystectomy is a good technique when performed in selected cases by expert surgeons. It is feasible to include the single port laparoscopic cholecystectomy in a major ambulatory surgery programme. We have not had serious complications. There is a high cosmetic satisfaction index with this technique.