Fournier's Gangrene after Open Hemorrhoidectomy without a Predisposing Factor: Report of a Case and Review of the Literature

Fournier's gangrene (FG) is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and vulva in women. An unpredictable case of FG two weeks after open hemorrhoidectomy in a previously healthy 55-year-old male is described. Full-thickness patchy skin necrosis of the perianal, perineal and scrotal region associated with rectal perforation was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Because of rectal involvement, diverting sigmoid colostomy was fashioned. The patient survived after two additional local debridements. Nevertheless, loss of sphincter function due to massive muscle destruction led to permanent colostomy. Our case together with others reported in the literature illustrates that, although rare, FG after open hemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. The development of fever and urinary retention should draw the attention of the surgeon, even if the presentation is delayed. The current literature only briefly mentions the potential risk of FG after such a common surgical procedure. However, devastating complications occur more often than anticipated. This disastrous complication without predisposing factor is discussed along with a literature review

Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy : Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study

In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical)

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

Aim: Demand for nipple-and skin-sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario. Methods: A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology. Results: The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recom-mendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR. Conclusions: The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BRPeer reviewe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Surgeon-performed intraoperative ultrasonography-guided excision of nonpalpable breast masses with adequate surgical margins under local anaesthesia

WOS: 000317861600006Aim With the improvement of expertise in technique and skills of ultrasonography (US), many surgeons now perform image-guided procedures for breast masses themselves. To minimize operative time, and to achieve adequate surgical margins with an acceptable cosmetic outcome, we designed a safe and simple hybrid technique to excise suspicious nonpalpable masses, which is described herein for the first time. Patients and Methods Intraoperatively-marked incision is performed, and a needle is advanced at a 0.5-cm distance to the lesion according to real-time ultrasound measurements. Four deep sutures are passed to fix and hang the predicted specimen adjacent to the needle in four directions. En bloc excision with aimed surgical margins of approximately 0.5cm is achieved by means of retracting sutures, and confirmed by specimen and tumour bed US. Results In the present study, there were 25 women (17 with malignant and 8 with benign lesions), with a mean age of 50.88 years (range: 3069) and mean tumour diameter of 10.6mm (range: 615). All lesions were correctly identified and localized by intraoperative US, and free margins of excision were obtained in all malignant lesions by means of the presented technique. The combined operative technical approach with surgeon-performed intraoperative US-guided needle placement and retracting sutures were feasible, simple and beneficial. We achieved complete tumour removal in all dimensions with no reexcision. The procedure was performed under local anaesthesia in an outpatient fashion with no complications. Conclusion Our report of the operative technique demonstrates that a combination of surgeon-performed image-guided localizations, together with a suture-oriented fashion to assure negative surgical margins in all dimensions, improves margin clearance rate at the time of first surgical intervention. This method can be performed with operative and cost efficiency, and might become a valuable tool to minimize operative time and yield minimal sacrifice of normal breast tissue with maximal cosmetic outcome

Favorable local control in breast cancer patients following sentinel lymph node biopsy after neoadjuvant chemotherapy without axillary lymph node dissection

20th Annual Meeting of the American-Society-of-Breast-Surgeons -- APR 30-MAY 05, 2019 -- Dallas, TXWOS: 000467382700235Amer Soc Breast Sur

Diagnostic adequacy of surgeon-performed ultrasound-guided fine needle aspiration biopsy of thyroid nodules

WOS: 000313708600017PubMed: 22766655Background Surgeon-performed ultrasonography (US) of thyroid nodules might serve as a potential therapeutic guide to designate accurate surgical or clinical intervention. Objective To evaluate the diagnostic adequacy of surgeon-performed ultrasonography guided fine needle aspiration biopsy (FNAB) of thyroid nodules, the factors responsible for diagnostic adequacy and the impact of surgeon-performed US on treatment approach. Methods Retrospective review of a single surgeon performed 621 US-guided FNABs without on-site cytological specimen assessment. Outside US findings were compared to the surgeon-performed US. Measured variables and outcomes for the study included diagnostic adequacy rates and the effects of detected differences between US reports on treatment variability. Results Diagnostic adequacy rate of surgeon-performed US-guided FNAB was determined to be 94.52% without on-site specimen evaluation by cytologist. Non-diagnostic specimens occurred in 34 of 621 (5.48%) nodules. The differences detected between the outside US and surgeon-performed US altered invasive treatment algorithm in 30 (5.47%) patients. FNAB was avoided for 15 (2.7%) patients. Total thyroidectomy became the preferred surgical option in 15 (2.7%) patients after the discovery of additional nodules in the contralateral lobe. Conclusion Surgeon-performed US offers clear clinical benefits in terms of diagnostic yield of FNAB with providing valuable additional data that might alter surgical treatment approach. J. Surg. Oncol. 2013;107:206210. (c) 2012 Wiley Periodicals, Inc

Axillary staging after neoadjuvant chemotherapy: The comparison of surgeon performed axillary ultrasound and 18F-FDG PET/CT with pathologic status of sentinel lymph nodes in clinically node-negative breast cancer

San Antonio Breast Cancer Symposium -- DEC 05-09, 2017 -- San Antonio, TXWOS: 00042548940033