Assessment of the delayed repair of uncomplicated inguinal hernias in infants.

BACKGROUND: Potential strangulation of infant inguinal hernias is the main indication for their urgent repair. Lack of theatre time delays repair and prolongs hospitalisation. We report a series of patients with uncomplicated hernias who were discharged home to have their elective surgery at a later stage and assessed the outcomes of this approach. METHODS: A retrospective audit was performed of all infants with an inguinal hernia from January 2010 to June 2015. Incomplete records and infants operated after their first birthday were excluded. Two groups were identified; immediate surgery for infants with uncomplicated hernias, and delayed surgery for infants with uncomplicated hernias. Incarceration/strangulation rates in the interim period were documented for the delayed group, and comparison made between the groups regarding perioperative and anaesthetic complications and length of postoperative hospital stay. RESULTS: The mean time delay between diagnosis and repair was 8.78 weeks. None of the hernias in the delay group strangulated while awaiting repair. There was no significant difference in the perioperative complications between the two groups. Out of the 70 cases in the immediate repair group, there was 7 (10%) surgical and 4 (5.7%) anaesthetic complications. The delayed group (169 infants) had 8 (4.7%) surgical and 6 (3.6%) anaesthetic complications. The incarceration rate after being discharged home was 4.1%. This group of infants had no anaesthetic or surgical complications. Length of hospital stay postoperatively was 1.43 days in the immediate group and 1.3 in the delayed group (p = .485). CONCLUSION: Delayed repair, up to 2 months later, for uncomplicated infant hernia carries a small risk of incarceration but does not increase the rate of strangulation or other complications.

Disparities in Breast Cancer: Private Patients Have Better Outcomes Than Public Patients.

INTRODUCTION: Different outcomes in breast cancer have been reported for low and high socio-economic groups. We present data quantifying disparities between South African public and private patients. METHODS: Records of 240 consecutive patients treated in 2008 in a public versus 97 patients in a private health facility were reviewed for demographic and oncologic data. RESULTS: The average of patients was 56.2 versus 51.9 years (p = 0.032). Stage at presentation was 0 in 0.83 versus 25.8%, I in 4.5 versus 15.5%, II in 41.3 versus 37.1%, III in 37.1 versus 18.6% and IV in 16.3 versus 3.1% public versus private patients. Seventy-three percent of patients were symptomatic versus 57.7%. Of patients with stage 0-III disease, 17.9 versus 20% had simple tumour excision and 7.5 versus 14%, oncoplastic tumour excision. The mastectomy rate was similar (52 vs. 60%), but immediate reconstruction was performed in 10 versus 63%. Public patients were less likely to have radiotherapy. The pathology was similar, 27.2 versus 20, 54 versus 52, 87 versus 61% of patients with stage I, II and III disease, respectively, had chemotherapy. Hormonal therapy for premenopausal patients in private was a LHRH agonist in 9.3%, ovarian ablation/BSO in 11.7% of public patients; biologicals were given in 7.2 versus 0% of patients. Overall survival for public versus private was 66 versus 80% (p < 0.001) months. Better per stage survival of private patients 100 versus 100, 72.7 versus 93.3, 84.8 versus 88.9, 57.3 versus 77.8 and 33 versus 33% for stages 0, I, II, III and IV, did not reach statistical significance. CONCLUSION: The greatest impact on outcome was stage at presentation, but more aggressive therapy for each stage resulted in a trend to better outcome for private patients.

Pharmacogenetics of Aromatase Inhibitors in Endocrine Responsive Breast Cancer: Lessons Learnt from Tamoxifen and CYP2D6 Genotyping.

BACKGROUND: Genetics play a significant role in drug metabolism of endocrine therapy of breast cancer. These aspects have been studied extensively in patients on tamoxifen, but the pharmacogenetics of aromatase inhibitors are less established. In contrast to the protective effect of tamoxifen, aromatase inhibitors are linked with an increased risk for bone loss and fractures. OBJECTIVE: This review outlines key issues in the implementation of pharmacogenetics of cytochrome P450 and tamoxifen as a model for optimal use of aromatase inhibitors in postmenopausal women with estrogen receptor positive breast cancer. METHODS: Lessons learnt from the association between tamoxifen and CYP2D6 genotyping were applied to identify polymorphisms with the potential to change clinical decision-making in patients on aromatase inhibitors. The ability of next generation sequencing to supersede single-gene analysis was furthermore evaluated in a subset of breast cancer patients on aromatase inhibitors selected from a central genomics database. RESULTS: Methodological flaws in major randomised controlled trials and continued referral to incorrect results in expert consensus statements are important factors delaying the implementation of CYP2D6 pharmacogenetics in tamoxifen treatment. This highlighted the importance of a clinical pipeline including comprehensive genotyping, to define the target population most likely to benefit from aromatase inhibitor pharmacogenetics. CONCLUSION: The clinical utility of CYP2D6 genotyping is well-established in patients at increased risk of tamoxifen resistance due to cumulative risk. The pharmacogenetics of CYP19A1 requires further clarification in terms of bone risk assessment for appropriate use in the treatment algorithm of high-risk patients at the onset of aromatase inhibitors.

Postmenopausal Breast Cancer, Aromatase Inhibitors, and Bone Health: What the Surgeon Should Know.

Breast cancer, as the most common malignancy in women, remains a major public health issue despite countless advances across decades. Endocrine therapy is the cornerstone of treatment of the hormone-sensitive subtype of breast cancer. The use of aromatase inhibitors (AIs) in the postmenopausal women has extended the survival beyond that of Tamoxifen, but harbors a subset of side effects, most notably accelerated bone loss. This, however, does not occur in all women undergoing treatment. It is vital to identify susceptible patients early, to limit such events, employ early treatment thereof, or alter drug therapy. International trials on AIs, predominantly performed in North American and European females, provide little information on what to expect in women in developing countries. Here, surgeons often prescribe and manage endocrine therapy. The prescribing surgeon should be aware of the adverse effect of the endocrine therapy and be able to attend to side effects. This review highlights clinical and biochemical factors associated with decrease in bone mineral density in an, as yet, unidentified subgroup of postmenopausal women. In the era of personalized medical care, appropriate management of bone health by surgeons based on these factors becomes increasingly important.

Results of a pilot programme of mammographic breast cancer screening in the Western Cape.

BACKGROUND: Mammographic screening programmes are now established in developing countries. We present an analysis of the first screening programme in sub-Saharan Africa. METHODS: Women aged > or = 40 years were identified at three primary healthcare centres in the Western Cape Province, South Africa, and after giving informed consent underwent mammography at a mobile unit. After a single reading, patients with American College of Radiology Breast Imaging Reporting and Data System (BIRADS) 3 - 5 lesions were referred to a tertiary centre for further management. RESULTS: Between 1 February 2011 and 31 August 2012, 2 712 screening mammograms were performed. A total of 261 screening mammograms were reported as BIRADS 3 - 5 (recall rate 9.6%). Upon review of the 250 available screening mammograms, 58 (23%) were rated benign or no abnormalities (BIRADS 1 and 2) and no further action was taken. In 32 women, tissue was acquired (biopsy rate for the series 1.2%); 10 cancers were diagnosed (biopsy malignancy rate 31%). For the entire series of 2 712 screening mammograms, the cancer diagnosis rate was 3.7/1 000 examinations. Of 10 cancers diagnosed at screening, 5 were TNM clinical stage 0, 2 stage I and 3 stage II. CONCLUSIONS: The low cancer detection rate achieved, and the technical and multiple administrative problems experienced do not justify installation of a screening programme using the model utilised in this series.

7-year follow up of intra-operative radiotherapy for early breast cancer in a developing country.

Scarce radiation resources and an often poor, rural population make single fraction, definitive intra-operative radiation (IORT) ideal for developing countries. From 2002 to 2005 IORT in breast conservation was administered utilizing existing infrastructure in an extremely resource-restricted environment. After tumor excision an applicator was introduced into the tumor bed. An existing Ir (192) after loader delivered a single fraction (21 Gy). Of thirty nine patients treated with 84 months follow-up, one patient suffered local, four regional and three systemic relapse. One patient died of disease, 2 of unrelated causes for a local control rate of 95% and a disease-specific survival of 95%. Cosmetic outcome was perceived excellent. IORT using existing after loaders and a low cost applicator greatly reduced health care resources. This extends breast conservation to indigent patients who cannot adhere to lengthy EBRT protocols.

A founder BRCA2 mutation in non-Afrikaner breast cancer patients of the Western Cape of South Africa.

Founder mutations in BRCA1 and BRCA2 have been reported in many different populations. We studied 105 Coloured and 16 Black Xhosa women residing in the Western Cape of South Africa diagnosed with breast cancer. We screened these patients using our standard panel of six previously reported SA Afrikaner and Ashkenazi Jewish BRCA1/2 mutations and identified only two Afrikaner mutations. Further screening by the protein truncation test (BRCA1 exon 11, and BRCA2 exons 10 and 11) revealed an additional four deleterious mutations (BRCA1 c.1504_ 1508del,p.Leu502AlafsX2, BRCA2 c.2826_2829del,p.Ile943LysfsX16, c.6447_6448dup,p.Lys2150IlefsX19 and c.5771_5774del,p.Ile1924Argfs X38). The latter, also known in Breast Cancer Information Core nomenclature as 5999del4, was identified in 4 of 105 (3.8%) Coloureds and 4 of 16 (25%) Xhosa women, which makes it a frequent founder mutation in the Western Cape Province. Although this mutation was previously reported to occur in the Netherlands, haplotype analysis indicated two distinct origins for the Dutch and South African mutations, excluding the possibility of a common Dutch ancestor and suggesting gene flow from the indigenous tribes such as the Xhosa to the Coloured population instead. Further studies to determine the carrier rate of this variant in the Xhosa and other SA populations are warranted.

Performance data of screening mammography at a dedicated breast health centre.

BACKGROUND: Mammographic screening has become part of routine health care. We present a first analysis of screening mammography in a dedicated breast health centre in Africa. OBJECTIVE: To establish a performance benchmark and provide data for health care policy and funding decisions on screening mammography. METHOD: All mammography performed between January 2003 and August 2008 was entered into a prospective database. Mammography was performed exclusively by certified mammographers and double-read by experienced readers. RESULTS: Outcomes were classified in a simplified classification system based on the Breast Imaging Reporting and Data System (BIRADS). In 40 - 49-year-old women, 3 192 mammograms led to a recall rate of 4.7%, a biopsy rate of 1.9% and a cancer diagnosis rate of 3.8 per 1 000 examinations; for women of 50 years and older, the corresponding figures were 4 446, 5.4%, 2.6% and 9.7 per 1 000. Of the cancers detected, 31% were in situ and, of the invasive cancers, 81% were node-negative. These figures were established by a dedicated surgeon-led team and fall within the range expected in organised screening programmes in resource-rich environments, providing a first benchmark for screening mammography in Africa.

Limited surgery and tamoxifen in the treatment of elderly breast cancer patients.

A conservative approach to treating breast cancer patients was adopted for those more than 70 years of age with T1-3 and small localized T4b N0-1 lesions. It consists of tumor excision or simple mastectomy with adjuvant tamoxifen. From the prospective breast cancer database, patients 70 years or older at the time of diagnosis were identified for the period January 1990 to December 1996. Demographic, clinical, pathological, and oncologic data were retrieved. A total of 236 patients were identified. Ninety-seven patients (41%) were treated according to the conservative protocol. Of these, 74 had a tumor excision and 23 had a simple mastectomy. Their mean age was 79 years. TNM staging was stage I in 18 patients, stage II in 66 patients, and stage III in 13 patients. There was no 30-day mortality. Eleven patients were not compliant with tamoxifen use. Two patients were lost to follow-up. The mean follow-up is 51 months (range 4 to 109 months). The cumulative incidence of local and regional recurrence at 8 years is 5% and 7%, respectively. Locoregional recurrences were controlled with excision, mastectomy, or axillary dissection. The cumulative disease-specific, overall, and disease-free survival at 5 years is 86%, 64% and 46%, respectively. Tumor excision or simple mastectomy with tamoxifen offers sufficient tumor control for elderly patients. Axillary dissection and breast or chest wall radiotherapy can safely be omitted, thereby greatly reducing health care resource utilization.

Breast Surgery International--breast cancer in developing countries.

Breast Surgery International (BSI) was formed in 1999 as an integrated society within the International Surgical Society ISS/SIC. One goal is to promote breast surgery world wide and focus on the situation in the developing countries. An edited summary of a symposium on locally advanced breast cancer (LABC) and the current situation in two African countries and in Malaysia is reported. Diagnosis, management and treatment options differ from recommendations that prevail due to lack of resources, lack of access to facilities and cultural and socioeconomic barriers. Younger age at onset, more men are affected and locally advanced breast cancer dominates the clinical panorama. A rational treatment plan for LABC should have chemotherapy, surgery, radiotherapy and hormonal therapy as armaments. A unique opportunity exists for international interchange within a professional organization such as BSI, for providing training opportunities, for clinical and experimental studies of the world' s most common female malignancy.

Malignant pericardial effusion in breast cancer: terminal event or treatable complication?

BACKGROUND: Few data are available on malignant pericardial effusion (MPCE) in breast cancer. We identify the patient prone to develop MPCE describe the result of surgical management, and try to identify a subgroup of patients who do not benefit from surgical management. METHOD: We performed an audit of our policy of active search for MPCE in breast cancer patients and its treatment by subxiphoid pericardial fenestration. RESULT: Nineteen patients with MPCE had a mean of 3.2 other sites of recurrence: 17 had pleural recurrence. Six patients had exertional dyspnea and 13 had dyspnea at rest; three needed emergency pericardiocentesis. An average of 740 ml of fluid was recovered; cytology was diagnostic in 11 cases and histopathology in 10 cases. At discharge, six patients had no dyspnea and six had exertional dyspnea. Of 10 patients who did not receive systemic treatment, eight died within 30 days. Nine patients who received systemic treatment had an average survival of 8.3 months. CONCLUSIONS: Patients with pleural recurrence presenting with dyspnea should be evaluated for the presence of a MPCE. Subxiphoid pericardial fenestration is the treatment of choice. Patients who will not receive systemic treatment should be managed conservatively.

Complications and outcome of external hemipelvectomy in the management of pelvic tumors.

BACKGROUND: Although the technique of external hemipelvectomy has been adequately described, little is known about its complications and late results. DESIGN: Retrospective review of 68 external hemipelvectomies performed at our Institute between 1973 and 1994. MATERIALS AND METHODS: Eleven patients had bone tumor; 39 patients, soft-tissue sarcoma; seven patients, melanoma; 10 patients, squamous cell carcinoma; and one patient, giant neurofibroma. In 48 (71%) patients, the intent was curative. In 17 cases, the hemipelvectomy was extended. RESULTS: Postoperative complications occurred in 36 (53%) patients, including flap necrosis in 11 (16%), wound infection in 24 (35%), and other complications in 12 (18%). Four (6%) patients died postoperatively. The average hospital stay after curative versus palliative resection was 39 versus 24 days. Only three (5%) patients were able to use a prosthesis, whereas 55 (81%) used crutches, six (9%) remained wheelchair bound, and four patients (6%) spent most of the time in bed. Local recurrence occurred in 35% of the patients. The estimated 5-year survival for curatively resected patients was 21%. CONCLUSIONS: External hemipelvectomy is a procedure with considerable morbidity and is indicated for only a minority of far-advanced tumors. It offers a chance of palliation and possibly cure when lesser surgical options have been exhausted.

Various types of hemipelvectomy for soft tissue sarcomas: complications, survival and prognostic factors.

Fifty-three hemipelvectomies were performed for primary or recurrent soft tissue sarcomas with fixation to the pelvis or peripelvic tissues. Resection was carried out in the absence of distant metastases in 70% of the cases. The hemipelvectomy was posterior in 66%, anterior in 6% and internal in 28%. Post-operative complications included wound edge necrosis in 19% and infection in 43% of cases. The mortality rate was 5.7%. Margins were macroscopically clear in 76% and marginal in 24% of cases. Tumours were high grade in 92%; their mean diameter was 16.5 cm. Local recurrence occurred in 19% and distant recurrence in 66% of patients. Overall survival was 39% at 2 years and 10% at 5 years. Pelvic soft tissue sarcomas have a poor prognosis. However, in the absence of other effective therapy, hemipelvectomy provides local control with acceptable morbidity in the majority of patients, with a small percentage (10%) surviving 5 years or longer.

Partial and complete internal hemipelvectomy: complications and long-term follow-up.

BACKGROUND: The complications and long-term follow-up results of internal hemipelvectomy are not well documented. STUDY DESIGN: We reviewed 32 internal hemipelvectomies performed between 1976 and 1994. RESULTS: The pathologic diagnoses were soft tissue sarcoma in 15 cases, bone tumor in 14 cases, melanoma in two cases, and carcinoma in one of the cases. In 24 cases, the intent of surgery was curative; in 22 cases, the procedure was modified. Average blood loss was 3.2 L; the procedure took on average 7.5 hours. Complications included skin flap necrosis in four cases, infection in 15 cases, and various other complications in five cases. Three mortalities (9 percent) occurred. Thirty-four percent of the patients ambulated without any assistance, 59 percent ambulated with crutches, while 7 percent remained wheel-chair bound. The survival rate after resection for cure was 45 percent at ten years compared with 29 percent at two years for palliative resections. CONCLUSIONS: Internal hemipelvectomy is a complex procedure that is functionally and cosmetically superior to external hemipelvectomy and, when done with curative intent, results in considerable long-term survival rates.

Breast cancer complicated by pleural effusion: patient characteristics and results of surgical management.

To evaluate the efficiency of pleurodesis (PD) in the management of symptomatic malignant pleural effusion (PE) in breast cancer, we reviewed 46 patients undergoing 49 PDs. When radiotherapy was part of the initial treatment, 41% of PEs were ipsilateral to the primary, if not, 85% of PEs were ipsilateral (P < 0.0075). Six percent of patients presented dyspneic with exertion, 32% during daily routine; 61% at rest. All except 1 were improved after PD; 74% had no dyspnea, 23% had exertional dyspnea. PD relieved chest pain in 4 and cough in 5 patients. With 31 Talc/Iodine PDs, 2 mortalities and 2 minor complications occurred. Of 17 tetracycline PDs, 1 was complicated by bronchopleural fistula and 1 failed. 1 Mustine PD was uncomplicated. Survival at 6, 12, and 24 months was 58%, 40%, and 13%, respectively. Primary local radiotherapy may prevent ipsilateral PE. Talc/Iodine and tetracycline PD reliably provide relief from the distressing symptoms of malignant PE.

Results of mandatory exploration for penetrating neck trauma.

Management of penetrating wounds to the neck remains controversial despite decades of discussion in the literature. We assessed 393 consecutive stab wounds penetrating the platysma operated at our trauma service between January 14, 1991 and September 30, 1992 to evaluate our policy of mandatory neck exploration (NE). Injury to the common (n = 19 cases), external (n = 7), internal carotid (n = 5), innominate (n = 2), subclavian (n = 20), vertebral (n = 12), facial (n = 2), and intercostal (n = 2) arteries; the external (n = 36), internal (n = 65), subclavian (n = 20), and innominate (n = 4) veins; the pharynx/esophagus (n = 21); and the trachea (n = 28) was considered a positive NE (n = 167). 226 NEs were negative. Except for hemiparesis and bruit, the presence of clinical signs (shock, active hemorrhage, hematoma, surgical emphysema, dysphagia, blowing wound) did not predict a positive NE. Clinical signs were absent in 30% of positive NEs and in 58% of negative NEs. Complications of positive NE included wound infection (n = 7 cases), chyle drainage (n = 6), cerebellar stroke (n = 1), pneumonitis (n = 8), reoperation for recurrent hemorrhage (n = 1), subclavian artery graft occlusion (n = 1), bronchopleural fistula (n = 1), and cerebrospinal fluid leak (n = 1). Negative NEs were complicated by a wound infection in four cases and pneumonitis in one case. The mean hospital stay was 4.3 days for those with a positive NE and 1.5 days for those with a negative NE.(ABSTRACT TRUNCATED AT 250 WORDS)