Breast Cancer Surgery During the COVID-19 Pandemic Peak in the UK: Operative Outcomes.

Introduction  The COVID-19 pandemic caused widespread changes in delivery of breast cancer care, aiming to protect vulnerable patients whilst minimising compromise to oncological outcomes. This multicentre observational study aimed to establish early surgical outcomes from breast cancer surgery performed during the peak of the COVID-19 pandemic.  Materials and methods  Data were collected on consecutive patients that underwent breast surgery in four units between 16 March and 24 April 2020. Outcome data at 30 days post-operation were collected, including documented COVID-19 cases in patients and reported cases in healthcare workers directly involved in their care. Recommended modifications to practice to reduce COVID-19 transmission risk, both to patients and healthcare workers in each centre, are described.  Results  A total of 202 patients underwent surgery in four hospitals delivering breast services in the West Yorkshire region over the six-week period at the peak of the pandemic. The age ranged from 28 to 91 years (median 57, interquartile range, 48-65) with 22% having co-morbidities linked to COVID-19, e.g. diabetes or respiratory disease. No patients presented post-operatively with COVID-19 symptoms and at 30 days there had not been any identified COVID-19 cases. There were no unexpected critical care admissions or deaths. One healthcare worker involved in the delivery of breast surgery was diagnosed with COVID-19 during this time and made an uneventful recovery.  Conclusion  Breast cancer surgery, in selected groups and with meticulous adherence to measures designed to reduce COVID-19 transmission, does not appear to be associated with elevated risk to patients or healthcare workers.

Mastectomy Without Drains Reduces Cost with No Detriment to Patient Outcome.

Introduction  Use of drains after mastectomy remains highly variable. This study aimed to establish whether simple mastectomy managed without a drain would cost less than the same procedure managed with a drain and whether there would be any difference in complications. Methods  Prospective data were collected on all patients undergoing simple mastectomy ± sentinel lymph node biopsy over sixteen months. Surgeons decided intra-operatively whether to place a drain. Data included operative details, mastectomy weight, length of stay and postoperative complications. Costing data were identified by combining hospital finance costs for admission and follow-up appointments along with the cost of consumables. Results  One hundred and thirty mastectomies were performed on 119 patients. There was a significant difference in mastectomy weight between drain group patients (n=80, median: 730g) and no drain group patients (n=50, median: 424g) (p=<0.001). The mean cost for drain group patients was £639.77 whilst for the no drain group was £365.46, indicating a potential unit saving of £21944.93 over sixteen months. Length of stay was shorter in the no drain group (range: 1-2 days) than the drain group (range: 1-4 days). The presence or absence of drains did not influence complication rates, with no change in seroma interventions (p=0.803). Conclusions  Managing simple mastectomy patients without a drain resulted in no increase in complications or subsequent interventions for seroma. Significant cost savings to both the hospital and to the patient can be achieved by omitting drain use. Routine use of drains in patients undergoing simple mastectomy ± SNB may be unnecessary and costly.

The role of magnetic resonance imaging in preoperative planning for patients undergoing therapeutic mammoplasty.

Background. Assessment of the ratio between tumour volume and breast volume in therapeutic mammoplasty is paramount. Traditionally based on clinical assessment and conventional breast imaging, the role of breast magnetic resonance imaging (MRI) in this context has not been established. Methods. Data was collected from all women undergoing therapeutic mammoplasty (TM) between 2006 and 2011. Each case was discussed at an MDT where MRI was considered to facilitate surgical planning. The contribution of MRI to disease assessment and surgical outcome was then reviewed. Results. 35 women underwent TM, 15 of whom had additional MRI. 33% of patients within the MRI subgroup had abnormalities not seen on either mammography or USS. Of those undergoing MRI, 1/15 patients required completion mastectomy versus 3 patients requiring completion mastectomy and 1 patient requiring further wide local excision (4/20) in the conventional imaging group. No statistical difference was seen between size on MRI and size on mammography versus final histological size, but a general trend for greater correlation between size on MRI and final histological size was seen. Conclusion. MRI should be considered in selected patients undergoing therapeutic mammoplasty. Careful planning can identify those who are most likely to benefit from MRI, potentially reducing the need for further surgery.

Breast conservation surgery: state of the art.

Breast conservation surgery is available to the vast majority of women with breast cancer. The combination of neoadjuvant therapies and oncoplastic surgical techniques allows even large tumours to be managed with a breast-conserving approach. The relationship between breast size and the volume of tissue to be excised determines the need for volume displacement or replacement. Such an approach can also be used in the management of carefully selected cases of multifocal or multicentric breast cancer. The role of novel techniques, such as endoscopic breast surgery and radiofrequency ablation, is yet to be precisely defined.

Acute abdomen due to retroperitoneal haematoma: a surgical dilemma.

A 73-year-old man presented with features of acute abdomen 2 days following evacuation of a subdural haematoma. CT scan demonstrated significant free fluid in the peritoneal cavity as well as an extensive abnormal area in the upper retroperitoneum. There was no obvious free gas or leak of contrast. As there was persistent metabolic acidosis and significant peritonism, the patient proceeded to an exploratory laparotomy. This revealed a large non-expanding retroperitoneal haematoma and free blood in the peritoneal cavity. There was no evidence of active bleeding and the bowel was found to be viable. As the patient was haemodynamically stable, a laparostomy was fashioned and the patient subsequently underwent angiography. This revealed a 1.5 cm pseudoaneurysm arising from the superior mesenteric artery which was treated with coil embolisation. The patient made an uneventful recovery and the laparostomy was closed.