Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction may predict post-mastectomy radiotherapy, reduce delayed complications and improve the choice of reconstruction.

BACKGROUND: Adjuvant post-mastectomy radiotherapy (RT), which is often unpredicted, is known to increase complications following immediate breast reconstruction (IBR). AIM: To investigate the role of sentinel lymph node biopsy (SLN) in predicting RT and improving the choice of IBR. PATIENTS AND METHODS: All patients who had mastectomy and IBR between January 2004 and January 2007 were reviewed retrospectively. Axillary staging (clearance or SLN) was performed at the same time until October 2005 (Group 1), when the Unit's protocol was updated to perform SLN initially prior to mastectomy and IBR (Group 2). Patients in Group 2 with positive SLN were offered either a delayed reconstruction or a temporary subpectoral immediate tissue expander, while all options were offered if SLN was negative and in Group 1 patients. RESULTS: One hundred and thirty-nine patients were reviewed. 20 patients received unexpected RT in Group 1 (14 tissue expander, 4 Latissimus Dorsi flap with an implant and 2 DIEP flaps) compared to 11 patients in Group 2 who had a temporary tissue expander due to expected RT (P=0.03). Unexpected RT caused delayed complications in 14 patients (70%) compared to no delayed complications in patients who received expected RT in Group 2. CONCLUSION: SLN biopsy before IBR helps to predict RT and avoids its complications on breast reconstruction. Patients with positive SLN biopsy are best offered a temporary subpectoral tissue expander for IBR.

Effectiveness and safety of carotid endarterectomy under remifentanil.

AIM: The aim of this study was to evaluate the effectiveness and safety of carotid endarterectomy (CEA) with conscious sedation under remifentanil (Remifentanil anesthesia - RA) vs conventional loco-regional anesthesia (Conventional-LRA) in the current practice of a vascular surgery unit. METHODS: We introduced the ''Remifentanil-RA'' in our practice according to a two-step protocol. In the first step we performed a pilot prospective study to assess the procedure's safety and reproducibility in our setting on 60 consecutive patients with symptomatic and/or high-grade (>70%) internal carotid artery stenosis and alternately assigning them either to ''Remifentanil-RA'' or ''Conventional-LRA'' CEA. In the second step we analysed our routine operative records as to effectiveness and safety on 533 patients who consecutively underwent ''Remifentanil-RA'' CEA. We compared them with 533 age- and sex-matched historical controls who underwent ''Conventional-LRA'' CEA. RESULTS: The patients' mean age was 71.2+/-6.8 vs 71.8+/-6.1 (''Remifentanil-RA'' vs ''Conventional-LRA''). About 73% of them were male and 56% had a symptomatic carotid stenosis. Neither the pilot study nor second step comparison showed differences in outcome measures. We found only higher peri-operative nausea/ vomit (3.6% vs 0.4% ''Remifentanil-RA'' vs ''Conventional-LRA'', P<0.0002) and fewer re-operations for post-operative hematomas (3% vs 5.4% respectively, P=0.048). CONCLUSIONS: We found that ''Remifentanil-RA'' CEA was safe, effective and satisfactory. Nevertheless, with the potential problems of intubation and those already found with side effects, a randomized control trial (RCT) is needed in order to prove that this method is superior to ''Conventional-LRA'' CEA.

[Propofol, fentanyl, nitrous oxide: useful and current combination?]. / Propofol, fentanyl, protossido di azoto: associazione utile ed attuale?

The introduction of use of propofol in the anesthetists' pharmacopoeia has reinvigorated the research for a totally intravenous anaesthesia, for which the Authors propose a diagram. However, in experience related to the supplementary use of N2O, in virtue of its analgesic power, demonstrates yet another utility, permitting an easier anesthetical administration with minor consumption of intravenous drugs.