Anaphylactic Reaction Rates to Blue Dyes Used for Sentinel Lymph Node Mapping: Systematic Review and Meta-analysis.

OBJECTIVE: The primary objective of this study was to quantify the risk of anaphylaxis to blue dyes used in SLNB for cancer. Secondary outcomes included the identification of factors that may influence this risk. SUMMARY OF BACKGROUND DATA: Blue dyes are widely used to help identify sentinel lymph nodes in oncological surgery. The rate of severe allergic reactions to blue dyes remains a controversial topic, with the true incidence and influencing factors uncertain. METHODS: A systematic review and meta-analysis was performed to identify all studies which report on the incidence of severe adverse reactions and anaphylaxis to blue dyes (patent blue, isosulfan blue, methylene blue, and indigo carmine), when used for SLNB. Collected data included cancer and dye type, volume, and method of injection. Incidence was estimated using the arcsine method of statistical analysis. RESULTS: One hundred nine studies documenting 94 episodes of anaphylaxis in a total of 61,951 SLNB procedures, resulting in a weighed anaphylaxis rate of 0.061%. SLNB for breast cancer carries an anaphylaxis risk of 0.083%, with the risk markedly lower in melanoma surgery (0.0043%). Low dye volume (<2 mL) and intradermal injection are both associated with lower rates of anaphylaxis (0.031% and 0.0068%). Isosulfan blue seems to be the most anaphylactogenic amongst blue dyes with a rate of 0.16%. There were no reported cases of death in this cohort. CONCLUSION: Anaphylaxis to blue dyes in SLNB is rare. Methylene blue, patent blue, lower dye volumes, and intradermal administration are all associated with a lower incidence of anaphylaxis.

Gusperimus: immunological mechanism and clinical applications.

Gusperimus is an immunosuppressive drug with a unique mode of action. We review its effects on different arms of the immune system and the current evidence for clinical applications, particularly in the treatment of transplant rejection and ANCA-associated vasculitis.

Giant pedunculated liver mass: primary hepatocellular carcinoma masquerading as hepatic haemangioma.

A woman in her mid-60s was referred to surgeons with a 2-week history of worsening right-sided abdominal pain. CT demonstrated a large encapsulated, pedunculated hepatic lesion with active intracapsular bleeding and free fluid but nil further lesions. Findings suggested giant hepatic haemangioma; surgical excision took place the following day. Histopathology however confirmed malignancy. Pedunculated hepatocellular carcinoma (HCC) is rare but characteristically large and encapsulated. Sporadic case reports indicate that diagnosis is typically challenging and delayed with liver metastases at presentation. This case describes a patient with no clear risk factors for HCC found to have a well-defined, encapsulated and pedunculated mass but no detected metastasis or other lesions on initial CT. In this instance, subsequent MRI did identify further lesions in the liver. Such cases are limited in the literature: much remains to be learnt regarding presentation, differential diagnoses, investigation and management.

Use of the self-retaining Alexis ring retractor in transoral robotic surgery.

BACKGROUND: Ring retractors, such as the Alexis® wound retractor, are simple devices used in a wide range of surgical settings to provide atraumatic exposure while protecting wound edges. METHODS: Here, we describe the application of the Alexis® to provide access during transoral robotic surgery (TORS). CONCLUSION: Its ease of application and many benefits, including maximization of intraoral space and protection of perioral soft tissues, make this device an excellent adjunct for TORS procedures.