Enhanced axillary assessment using intradermally injected microbubbles and contrast-enhanced ultrasound (CEUS) before neoadjuvant systemic therapy (NACT) identifies axillary disease missed by conventional B-mode ultrasound that may be clinically relevant.

PURPOSE: The purpose of this study is to measure pre-treatment diagnostic yield of malignant lymph nodes (LN) using contrast-enhanced ultrasound (CEUS) in addition to B-mode axillary ultrasound and compare clinicopathological features, response to NACT and long-term outcomes of patients with malignant LN detected with B-mode ultrasound versus CEUS. METHODS: Between August 2009 and October 2016, NACT patients were identified from a prospective database. Follow-up data were collected until May 2019. RESULTS: 288 consecutive NACT patients were identified; 77 were excluded, 110 had malignant LN identified by B-mode ultrasound (Group A) and 101 patients with negative B-mode axillary ultrasound had CEUS with biopsy of sentinel lymph nodes (SLN). In two cases CEUS failed. Malignant SLN were identified in 35/99 (35%) of B-mode ultrasound-negative cases (Group B). Patients in Group A were similar to those in Group B in age, mean diagnostic tumour size, grade and oestrogen receptor status. More Group A patients had a ductal phenotype. In the breast, 34 (31%) Group A patients and 8 (23%) Group B patients achieved a pathological complete response (PCR). In the axilla, 41 (37%) and 13 (37%) Groups A and B patients, respectively, had LN PCR. The systemic relapse rate was not statistically different (5% and 16% for Groups A and B, respectively). CONCLUSIONS: Enhanced assessment with CEUS before NACT identifies patients with axillary metastases missed by conventional B-mode ultrasound. Without CEUS, 22 (63%) of cases in Group B (negative B-mode ultrasound) may have been erroneously classed as progressive disease by surgical SLN excision after NACT.

Intraoperative cholangiography in modern surgical practice.

BACKGROUND/AIMS: The aim of this study was to assess the practice of performing intraoperative cholangiography (IOC) during laparoscopic cholecystectomy in a busy teaching hospital. METHODS: Data were obtained from a surgical database for patients who underwent laparoscopic cholecystectomy between January 2000 and December 2003. The findings of IOC and follow-up were analysed. RESULTS: 1,651 patients were included in the study. Of the 745 patients (45.1%) who underwent IOC, this was normal in 586 patients and abnormal in 68 patients. Of these 68 patients, 4 underwent immediate conversion to open common bile duct exploration. 33 patients underwent endoscopic retrograde cholangiopancreatography and 31 patients were observed. During a median follow-up period of 920 days (range 371-1,821), 5 of the 745 patients had retained stones. Two patients re-presented after a failed IOC while 5 of the 906 patients from the non-cholangiogram group returned with stones. Of the 1,651 patients, definite stones were identified in 1.5% patients. CONCLUSION: When the surgeon deemed that IOC was not required, very few subsequent problems were encountered. An observational policy with monitoring of the liver function tests may be appropriate to avoid unnecessary invasive interventions in patients with an abnormal IOC.

Variations in the assessment practice for renal transplantation across the United Kingdom.

BACKGROUND: To investigate whether there are any variations in the evaluation of adult candidates for cadaveric renal transplantation among transplant centers in the United Kingdom. METHODS: An online survey of transplant units in the United Kingdom, including nephrologists, surgeons, and transplant coordinators, measured differences in the assessment process and evaluation of patient's age, body mass index (BMI), cardiovascular comorbidity, and viral serology. RESULTS: A response was received from 20 out of the 23 centers (87%). These centers perform 90% of all renal transplants in the United Kingdom. In 30% of the units, there is no formal transplant assessment clinic. There is no cutoff age limit for assessment across the United Kingdom, but 12 centers (60%) exclude patients with a high BMI, with a median cutoff BMI of 35. Eight out of the 20 centers do not give cytomegalovirus (CMV)-negative patients the option to receive kidneys from a CMV-positive donor. Hepatitis C antibody-positive donors are not used in 50% of the units. There is considerable variation in the investigation of cardiovascular disease and exclusion criteria based on cardiovascular status of the patients. Five units have no consistent policy of re-evaluating patients once they are listed. CONCLUSIONS: There is evidence, from this study, of significant variations in the assessment of patients for renal transplantation across the United Kingdom. Further research and better-defined guidelines are required for a uniform assessment process and to ensure equity of access to the renal transplant waiting list.

Banana leaf dressing for skin graft donor areas.

Skin grafting is an integral part of burn wound management. The pain experienced at skin graft donor sites is significant. Banana leaf dressing (BLD) developed by our unit in 1996 is an excellent, non-adhesive, pain-free, cheap and easily available dressing material. We conducted a trial to compare efficacy of BLD with vaseline gauze (VG) dressing used by majority of burns centers for dressing skin graft donor areas. Thirty patients undergoing skin grafting were included in the study. BLD was applied on one half and VG on the other half of the donor area. Dressing change was done on the eighth day. Using the visual analogue scale we assessed the pain score, the dressing removal pain score and ease of dressing removal score. The advantage of early epithelisation of donor areas cannot be over stressed in burnt patients. The epithelisation status of the donor area on eight post-operative day was noted. The day of complete epithelisation was also noted. The average pain score with BLD was 1.1+0.71 while that with VG was 6.9+0.84. The average dressing removal pain score was 0.97 with BLD while that with VG it was 9.47. Ease of dressing removal score average was 1.1 with BLD while it was 9.53 with VG. In all the above scores the difference observed was statistically significant with P<0.001. The mean complete epithelisation day was 8.67 in the BLD covered areas as compared to 11.73 in the VG covered areas. This observation was highly significant with P<0.001. Our study clearly indicates that BLD is a completely non-adherent and painless dressing. We strongly recommend the use of BLD for all skin graft donor areas.

Evaluation of banana leaf dressing for partial thickness burn wounds.

An important factor in the healing of superficial and moderate partial thickness burn is early and effective coverage with a dressing that protects the wound from trauma and dessication and is non-adherent. In our country cost is also a very important factor. Disturbed by the pain and anxiety experienced by the patients during and after dressing changes, search for a new dressing material was begun for partial thickness burn wounds and the banana leaf dressing (BLD) was subsequently developed and optimised by June 1996. An open controlled study was carried out to compare banana leaf dressing and boiled potato peel bandage (BPPB), the dressing being used in our Burn Unit since 1994. Thirty patients all less than 40 years of age, with burn size less than 50% TBSA, involving comparable body areas with partial thickness burn, were included in the study. BLD along with a topical agent was applied over the right sided extremity while BPPB was applied with the same topical agent on the left sided extremity. Dressing was changed every day. The pain during dressing change, feeling of comfort and ease of handling dressing was assessed by awarding scores by the patients and care givers for each type of dressing. Analysis of the scores revealed that both BLD and BPPB caused easily tolerable, minimal pain during dressing change in majority of the patients. The days taken for epithelialisation, eschar formation and the need for skin grafting over deep partial thickness burns, did not reveal any significant difference between the areas treated by BLD and those by BPPB. So both the dressings were observed to have equal efficacy in protecting the wounds and aiding healing. Thus, the efficacy of BLD and BPPB was parallel in all respects. But BLD is 11 times cheaper than BPPB. Banana plants can be easily grown, the leaves are easily available throughout the year. The leaves of banana are large thus offering larger surface area and the surface is non-adherent, waxy and cool. The dressing can be prepared very easily with little training. It is also the cheapest dressing available today. We strongly recommend the use of banana leaf dressing for all partial thickness burn wounds in our environment.