Effect of Lavage with Gentamicin vs. Clindamycin vs. Physiologic Saline on Drainage Discharge of the Axillary Surgical Bed after Lymph Node Dissection.

BACKGROUND: To date, without placement of a drain, seroma formation cannot be avoided after axillary lymph node dissection (ALND). The purpose of this study was to evaluate the effect on drainage volume of pre-closure axillary lavage with physiologic saline, gentamicin solution, or clindamycin solution. METHODS: A randomized study was performed between January 2013 and October 2014. Inclusion criteria were a diagnosis of breast neoplasm and plans to undergo an elective ALND because of axillary metastases. The patients were randomized into three groups: Two lavages with 500 mL of physiologic saline (Group 1), lavage with 500 mL of saline followed by lavage with 500 mL of a 240-mg gentamicin solution (Group 2), and lavage with 500 mL of saline followed by lavage with 500 mL of a 600-mg clindamycin solution (Group 3). RESULTS: A total of 51 patients were included. The mean number of days with a drain in place was 7.1±3 in Group 1, 4.1±1.2 in Group 2, and 6.4±2.1 in Group 3 (p<0.001). Total drainage volume before tube removal was 435.3±220.1 mL in Group 1, 155.2±82.4 mL in Group 2, and 352.3±212.9 mL in Group 3 (p=0.03). In a pairwise analysis, irrigation with gentamicin solution achieved a lower drainage volume and a reduction in the number of days of drainage maintenance compared with the other two groups. CONCLUSION: The post-operative output of the axillary drain is substantially lower in patients undergoing lavage of the surgical bed with a gentamicin solution than in patients undergoing lavage with physiologic saline or clindamycin solution.

Effect of gentamicin lavage of the axillary surgical bed after lymph node dissection on drainage discharge volume.

UNLABELLED: The purpose of this study was to evaluate the effect of axillary lavage with a gentamicin solution before wound closure on drainage volume. PATIENTS AND METHODS: A prospective, randomized study was performed. Inclusion criteria were a diagnosis of breast neoplasms and plans to undergo an elective axillary lymph node dissection due to axillary metastasis. The patients were randomized into 2 groups: patients undergoing 2 lavages with 500 ml normal saline (Group 1) and patients first undergoing lavage with 500 ml normal saline followed by a second lavage with a 500 ml of a gentamicin (240 mg) solution (Group 2). Microbiological samples were obtained before any lavage, after each lavage and at the time of drain removal. RESULTS: 40 patients were included. Mean number of days maintaining the drain in place was 7.7 ± 3.2 days in Group 1 and 4.3 ± 1.4 days in Group 2 (p = 0.001). Total drainage volume before removal was 465 ± 250.9 ml in Group 1 and 169 ± 102.2 ml in Group 2 (p = 0.003). After a second lavage with normal saline in Group 1 and after a lavage with gentamicin solution in Group 2, microbiological culture was positive in 10 patients (50%) in Group 1 and 1 case (5%) in Group 2 (p = 0.016). Positive cultures were associated with higher drainage volumes. CONCLUSION: The postoperative drainage volume of the axillary drain is significantly lower in the patients undergoing a lavage of the surgical bed with a gentamicin solution than in the control group undergoing a lavage with normal saline. A significant reduction in the contamination is only obtained after a lavage with gentamicin solution. CLINICAL TRIAL REGISTRATION NUMBER: NCT01700504.

Valoración de la 5ª edición de la clasificación TNM para el cáncer gástrico en nuestro medio / Appraisal of the fifth edition of the tumor-node-metastasis (TNM) classification for gastric cancer in our environment

Objetivo. Evaluar el número de casos de carcinoma gástrico que pueden ser estadificados con los criterios de la 5.a edición del sistema TNM y analizar qué factores pueden estar relacionados con la obtención de un número suficiente de ganglios. Pacientes y método. En 164 pacientes a los que se resecó un carcinoma gástrico, se estudiaron distintos factores que podían influir en el número de ganglios aislados, como el tamaño tumoral, el tipo de resección gástrica, el grado de diferenciación tumoral, el tipo histológico, la variabilidad entre patólogos que analizaron las piezas y la experiencia del cirujano. Resultados. La media de ganglios linfáticos analizados por los patólogos fue de 11,4 (intervalo de confianza del 95%, 10,12-12,66). Atendiendo a los criterios de la 5.a edición de la clasificación TNM, sólo se pudo clasificar correctamente al 31% de los pacientes. Encontramos una correlación positiva entre el tamaño tumoral y el número de ganglios aislados (p = 0,0018), así como un mayor número de ganglios analizados en las gastrectomías totales respecto de las subtotales (p = 0,034). No se observó una variación significativa en los ganglios analizados en relación con el patólogo que analizó la pieza ni con la experiencia del cirujano que efectuó la resección. Conclusiones. La 5.a edición del sistema TNM es fácilmente reproducible, aunque el número de ganglios necesarios para corroborar la afección ganglionar metastásica es difícil de conseguir en nuestro medio. Nuestros resultados sugieren que es necesario un esfuerzo conjunto por parte de cirujanos y patólogos para aumentar el número de pacientes estadificables con esta edición (AU)

Aim. To estimate the proportion of patients with gastric carcinoma that can be classified using the criteria of the fifth edition of the TNM system and to analyze which factors could be related to the finding of an adequate number of nodes. Patients and method. The influence of distinct factors that could influence the number of lymph nodes isolated was evaluated in 164 patients who underwent resection of gastric carcinoma. These factors included tumor size, surgical resection, grade, histological type, variability among the pathologists who analyzed the surgical specimens, and the surgeon's experience. Results. The mean number of lymph nodes examined by the pathologists was 11.4 (10.12-12.66). Applying the criteria of the fifth edition of the TNM classification, only 31% of the patients could be correctly classified. A positive correlation was found between tumor size and the number of resected nodes (p = 0.0018). In addition, a greater number of lymph nodes were found in total gastrectomies than in subtotal gastrectomies (p = 0.034). No significant association was found with the pathologist who analyzed the surgical specimen or with the experience of the surgeon who performed the resection. Conclusions. The fifth edition of the TNM system is easily reproducible, although the number of lymph nodes required to evaluate metastatic node involvement is difficult to obtain in our environment. Our results suggest that a combined effort between surgeons and pathologists is needed to increase the number of patients that can be reliably staged with this TNM edition (AU)

Adecuación de las unidades de mama españolas a los criterios de EUSOMA / EUSOMA requirements for breast cancer units in Spain

Introducción. El planteamiento multidisciplinario del cáncer de mama en unidades especializadas se considera el más adecuado, tanto en el beneficio para la paciente como en el consumo más racional de recursos materiales. Con estas premisas se han elaborado las recomendaciones de la European Society of Mastology (EUSOMA) encaminadas a dotar a todos los países europeos de equipos multidisciplinarios de alta calidad. Material y método. En este trabajo se presentan y se analizan los resultados obtenidos de la encuesta sobre unidades de mama, promovida por la Sección de Patología de la Mama de la Asociación Española de Cirujanos, en 241 hospitales españoles. Resultados. Destaca la elevada implicación de los servicios de cirugía general (131 hospitales) en la atención de la patología mamaria, así como el gran interés por la formación continuada de los cirujanos españoles (el 41,2% de los servicios posee un título de posgrado). En 95 (73,6%) hospitales se planifica el proceso terapéutico, mediante reunión multidisciplinaria regular. Existen protocolos escritos sobre diagnóstico y tratamiento en 119 (90,8%) de los servicios que se dedican a la patología mamaria y se aplican medios para mantener un adecuado control de la calidad asistencial en 83 (63,4%) hospitales. Conclusiones. Resaltamos la necesidad de una normativa española sobre unidades de mama, preferiblemente adaptada a los criterios de EUSOMA, que son los admitidos por el comité encargado del Parlamento Europeo. La Asociación Española de Cirujanos, a través de la Sección de Patología de la Mama, debe ejercer un destacado papel a la hora de acreditar a los médicos de las unidades de mama y potenciar la formación continuada de éstos (AU)

Introduction. The optimal treatment of breast cancer consists of a multidisciplinary approach in specialized units, benefitting patients and leading to more rational resource use. Based on these premises, the European Society of Mastology (EUSOMA) drew up recommendations designed to provide all European countries with high-quality multidisciplinary teams. Material and method. We present and analyze the results obtained from a survey of breast cancer units in 241 Spanish hospitals performed by the Breast Diseases Group of the Spanish Association of Surgeons. Results. Breast disease was treated in general surgery departments in 131 hospitals and Spanish surgeons showed strong interest in continuing training (41.2% had a postgraduate degree in mastology). Multidisciplinary discussions at weekly intervals took place in 95 hospitals (73.6%) hospitals for planning a diagnostic and therapeutic course of action specific for each patient. Written protocols for diagnosis and treatment were used in 119 departments (90.8%) and quality control measures were applied in 83 (63.4%). Conclusions. We stress the need for mandatory requirements in Spain for breast cancer units, preferably adapted to the EUSOMA criteria, which are accepted by the relevant committee of the European Parliament. Through its Breast Diseases Group, the Spanish Association of Surgeons should be involved in accreditation standards for breast surgeons and should promote adequate specialization programs (AU)

Aplicación de los criterios de EUSOMA en las unidades funcionales de mama de los países miembros de la Unión Europea / Application of the eusoma criteria in breast units in countries of the European Union

Todos los países de la Unión Europea se enfrentan a retos similares a la hora de ofrecer un tratamiento adecuado y de alta calidad a los pacientes oncológicos. Los “Requisitos de una Unidad de Mama” publicados en 2000 y resultado del trabajo de un grupo de expertos representan la opinión de la European Society of Mastology (EUSOMA) sobre los estándares de composición y funcionamiento necesarios para formar unidades de cáncer de mama de alta calidad. Hemos estudiado la aplicación de las recomendaciones y de los requisitos obligatorios: cantidad crítica o número mínimo de pacientes, composición y formación específica del personal médico, control de calidad, aplicación de protocolos, etc. Los datos se han obtenido a partir de una completa búsqueda bibliográfica, complementada con la información procedente de buscadores médicos, páginas web de sociedades científicas, asociaciones nacionales de lucha contra el cáncer, ministerios de sanidad, etc., de los países miembros de la Unión Europea. Se han actualizado las últimas actuaciones de la Comisión del Parlamento Europeo responsable del informe sobre el cáncer de mama. Hay diversos enfoques de atención multidisciplinaria de la enfermedad mamaria en algunos países europeos, como los desarrollados en el Reino Unido, Suecia, Italia, Francia o España. Sería conveniente disponer de una normativa europea común para poder mejorar el cuidado de nuestras pacientes (AU)

All the countries of the European Union face similar challenges when providing adequate and high quality treatment in oncology. A working party was established to consider what should comprise a specialist service and the “Requirements of a Breast Unit”, published in 2000, represent the opinion of the European Society of Mastology (EUSOMA) on the standards required for creating high quality Breast Cancer Units across Europe. We studied the application of the mandatory requisites and general recommendations of EUSOMA: critical mass, or minimum number of patients, core team (composition and specific training), quality assurance, and application of diagnostic and treatment protocols. A thorough literature search was performed and was completed with information from search tools, the web pages of scientific societies, national associations for the fight against cancer, and health ministries of the countries belonging to the European Union. We also analyzed the latest reports of the European Parliamentary Committee for breast cancer. Distinct approaches to the multidisciplinary management of breast disease can be found in the United Kingdom, Sweden, Italy, France and Spain. A common European standard would be useful to improve the care provided to patients (AU)

[Assessment of the fifth edition of the tumor-node-metastasis (TNM) classification for gastric cancer in our setting]. / Valoración de la 5.a edición de la clasificación TNM para el cáncer gástrico en nuestro medio.

AIM: To estimate the proportion of patients with gastric carcinoma that can be classified using the criteria of the fifth edition of the TNM system and to analyze which factors could be related to the finding of an adequate number of nodes. PATIENTS AND METHOD: The influence of distinct factors that could influence the number of lymph nodes isolated was evaluated in 164 patients who underwent resection of gastric carcinoma. These factors included tumor size, surgical resection, grade, histological type, variability among the pathologists who analyzed the surgical specimens, and the surgeon's experience. RESULTS: The mean number of lymph nodes examined by the pathologists was 11.4 (10.12-12.66). Applying the criteria of the fifth edition of the TNM classification, only 31% of the patients could be correctly classified. A positive correlation was found between tumor size and the number of resected nodes (p = 0.0018). In addition, a greater number of lymph nodes were found in total gastrectomies than in subtotal gastrectomies (p = 0.034). No significant association was found with the pathologist who analyzed the surgical specimen or with the experience of the surgeon who performed the resection. CONCLUSIONS: The fifth edition of the TNM system is easily reproducible, although the number of lymph nodes required to evaluate metastatic node involvement is difficult to obtain in our environment. Our results suggest that a combined effort between surgeons and pathologists is needed to increase the number of patients that can be reliably staged with this TNM edition.

[Application of the EUSOMA criteria in breast units in countries of the European Union]. / Aplicación de los criterios de EUSOMA en las unidades funcionales de mama de los países miembros de la Unión Europea.

All the countries of the European Union face similar challenges when providing adequate and high quality treatment in oncology. A working party was established to consider what should comprise a specialist service and the Requirements of a Breast Unit, published in 2000, represent the opinion of the European Society of Mastology (EUSOMA) on the standards required for creating high quality Breast Cancer Units across Europe. We studied the application of the mandatory requisites and general recommendations of EUSOMA: critical mass, or minimum number of patients, core team (composition and specific training), quality assurance, and application of diagnostic and treatment protocols. A thorough literature search was performed and was completed with information from search tools, the web pages of scientific societies, national associations for the fight against cancer, and health ministries of the countries belonging to the European Union. We also analyzed the latest reports of the European Parliamentary Committee for breast cancer. Distinct approaches to the multidisciplinary management of breast disease can be found in the United Kingdom, Sweden, Italy, France and Spain. A common European standard would be useful to improve the care provided to patients.

[EUSOMA requirements for breast cancer units in Spain]. / Adecuación de las unidades de mama españolas a los criterios de EUSOMA.

INTRODUCTION: The optimal treatment of breast cancer consists of a multidisciplinary approach in specialized units, benefitting patients and leading to more rational resource use. Based on these premises, the European Society of Mastology (EUSOMA) drew up recommendations designed to provide all European countries with high-quality multidisciplinary teams. MATERIAL AND METHOD: We present and analyze the results obtained from a survey of breast cancer units in 241 Spanish hospitals performed by the Breast Diseases Group of the Spanish Association of Surgeons. RESULTS: Breast disease was treated in general surgery departments in 131 hospitals and Spanish surgeons showed strong interest in continuing training (41.2% had a postgraduate degree in mastology). Multidisciplinary discussions at weekly intervals took place in 95 hospitals (73.6%) hospitals for planning a diagnostic and therapeutic course of action specific for each patient. Written protocols for diagnosis and treatment were used in 119 departments (90.8%) and quality control measures were applied in 83 (63.4%). CONCLUSIONS: We stress the need for mandatory requirements in Spain for breast cancer units, preferably adapted to the EUSOMA criteria, which are accepted by the relevant committee of the European Parliament. Through its Breast Diseases Group, the Spanish Association of Surgeons should be involved in accreditation standards for breast surgeons and should promote adequate specialization programs.

Estado actual del tratamiento multidisciplinario del cáncer gástrico avanzado / Current status of multidisciplinary treatment of advanced gastric cancer

La cirugía continúa siendo el único tratamiento curativo para los enfermos con carcinoma gástrico avanzado. Sin embargo, la recidiva es muy frecuente en estos enfermos. Durante los últimos 15 años, el debate se ha focalizado en la efectividad de la cirugía radical, fundamentalmente en lo concerniente a la realización de linfadenectomías ampliadas, y en la búsqueda de tratamientos locorregionales y sistémicos, sobre todo la quimioterapia, atendiendo al patrón de recidiva de esta neoplasia. En esta revisión hemos analizado los resultados obtenidos por estos tratamientos basándonos en los estudios que parecían aportar una mayor evidencia científica. Las principales conclusiones son: a) continúa sin demostrarse la efectividad de la linfadenectomía ampliada al segundo nivel y, en el caso más favorable, se limitaría a los estadios II y IIIa; b) el incremento de la morbimortalidad asociada a este tipo de cirugía podría minimizarse evitando la resección de la cola de páncreas y restringiendo la realización de esplenectomías a pacientes seleccionados; c) los estudios de metaanálisis muestran que la quimioterapia ofrece resultados insuficientes, aunque existen estudios recientes que deben ser contrastados; d) parece interesante tener en cuenta el patrón de quimiorresistencia de estas neoplasias para seleccionar a los enfermos que van a ser tratados con quimioterapia y elegir la asociación de fármacos en función del mismo; e) la información extraída del lavado peritoneal puede ser un factor predictor de recidiva muy útil si mejora su sensibilidad y el valor predictivo negativo, y f) el seguimiento exhaustivo de estos enfermos no puede recomendarse de forma sistemática debido a la baja sensibilidad de los métodos disponibles para detectar la carcinomatosis peritoneal precoz, así como a la ausencia de un tratamiento efectivo de la recidiva (AU)