Fernando Hernanz

Colorectal adenocarcinoma:: Quality of the assessment of lymph node metastases

PURPOSE: We have studied 193 cases of colorectal adenocarcinoma from a population-based register to determine the minimum number of lymph nodes to be examined to provide an accurate assessment of the presence of nodal metastases. METHODS: The mean total number of lymph nodes identified per surgical specimen was 11 ±6.8 (range, 1–36) using traditional dissection. One hundred eighteen specimens (61 percent) were classified as Dukes B. Seventy-five (39 percent) had lymph node metastases (Dukes C) with a mean of 3.3±4.7 positive lymph nodes per specimen. With binomial distribution we calculate the probability to find at least one positive node in a sample size n with a determined proportion of positive nodes. RESULTS: The error probability in the ganglionar assessment by traditional dissection was 0.05 with 6 examined lymph nodes and 0.01 with 10 examined nodes. CONCLUSION: We must provide the pathologist with a minimum of six examined lymph nodes per surgical specimen for an optimal Dukes B assessment.

Liver Transplantation in a Case of Steatohepatitis and Subacute Hepatic Failure after Biliopancreatic Diversion for Morbid Obesity

Background: Biliopancreatic diversion (BPD) was designed to avoid the serious complications of jejunoileal bypass (steatohepatitis and hepatic failure). Although this is today considered a safe and effective procedure, a few reports of patients who developed steatohepatitis and subsequently died in hepatic failure exist. Methods: We report a morbidly obese patient who developed subacute hepatitis resulting in hepatic failure 1 year after BPD. Results: Because of irreversible liver failure the decision to perform a liver transplantation was made.The patient underwent emergency liver transplant and lengthening of the common limb. The course of liver transplantation and the patients recovery were uneventful. Conclusion: Severe liver disease may rarely follow BPD. Liver transplantation and lengthening of the common bowel may be performed to treat these patients.

Oncoplastic Breast-Conserving Surgery: Analysis of Quadrantectomy and Immediate Reconstruction with Latissimus Dorsi Flap

BackgroundOncoplastic breast-conserving surgery satisfies oncologic principles and improves cosmetic outcomes, even when an important breast volume excision is required.MethodsWe reviewed 28 patients suffering from breast cancer treated with quadrantectomy and immediate myocutaneous latissimus dorsi flap reconstruction. We evaluated the status of the surgical margins, early complications, and cosmetic outcome. Cosmetic assessment was carried out by a panel made up of three women and one man: a female member of an association against breast cancer, a female general practitioner, a female gynecologic resident, and a male breast-specialized surgeon.ResultsFree margins were obtained in all cases. There were 11 postoperative complications: 9 seromas at the donor site, 1 dehiscence of the back wound, and 1 minor partial flap skin necrosis. Chemotherapy and radiotherapy adjuvant treatment was not compromised. The cosmesis outcome was deemed to be good in 43.75% of the cases and satisfactory in 56.25%. The score for overall cosmesis outcome was 6.92 out of 10. Symmetry and the scar of the reconstructed breast were the most influential criteria in the quantitative assessment of overall cosmetic results.ConclusionPartial mastectomy (quadrantectomy) and immediate reconstruction with a myocutaneous latissimus dorsi flap allows extensive resection, which fits oncologic requirements, without serious morbidity and a good cosmetic outcome.

Oncoplastic Techniques Extend Breast-Conserving Surgery to Patients with Neoadjuvant Chemotherapy Response Unfit for Conventional Techniques

BackgroundOncoplastic surgery is extending the role of breast-conserving surgery in an increasing number of patients who are unsuitable for conventional breast-conserving techniques. The aim of this retrospective study was to analyze the surgical approach, oncoplastic surgery guided by bracketing, used in the treatment of patients who required a wide breast tissue excision after neoadjuvant chemotherapy. The parameters evaluated were as follows: margin status, rate of re-excision for positive margin, early ipsilateral recurrence, and cosmetic outcomes.MethodsA total of 23 patients were treated with an oncoplastic breast-conserving surgery one-stage procedure using volume-replacement (20) and volume-displacement techniques (3). We reviewed medical records, mammograms and magnetic resonance images. Cosmetic assessment was carried out by a mixed panel made up of three women: a general practitioner, a resident general surgeon and a nurse.ResultsAll margins were negative and none of the patients had to have a re-excision for positive margins. One ipsilateral local recurrence was observed after a 32-month follow-up period. Cosmetic outcome was good, with an overall score of 8 out of 10.ConclusionsOncoplastic techniques extend breast-conserving surgery to patients with neoadjuvant chemotherapy response unfit for conventional techniques. The surgical approach combining oncoplastic techniques with bracketing allows breast-conserving surgery to be performed in these patients.

Reduction mammaplasty: An advantageous option for breast conserving surgery in large-breasted patients

Oncoplastic breast conserving surgery is a good approach for large-breasted women with breast cancer, as it increases the rate of breast conserving surgery, improves cosmetic results and prevents both cosmetic sequelae and the symptoms associated with macromastia. We reviewed ten publications in which 276 patients had been treated with bilateral reduction mammaplasty. All showed the same conclusion: women with breast cancer and macromastia candidates for breast conserving surgery could obtain clear oncological and cosmetic advantages and an improvement in quality of life if they were treated using bilateral reduction onco-therapeutic mammaplasty.

Application of the POSSUM system in bariatric surgery.

Background: The POSSUM system has been devised for physiologic and operative scoring. The scoring system produced assessment for morbidity and mortality rates, which did not significantly differ from observed rates. The authors have applied this system to bariatric surgery. Patients and Methods: 20 patients were scored by the POSSUM system. All underwent elective bariatric surgery during 1997. All patients were scored at the time of surgery with the physiologic score (FIS) and at discharge with the operative severity score (IQ). The FIS score included age; cardiac signs; chest radiograph; respiratory history; blood pressure; pulse; Glasgow coma score; determinations of hemoglobin, leukocyte, urea, sodium, and potassium levels; and electrocardiogram. The IQ score included multiple procedures, total blood loss, peritoneal soiling, presence of malignancy, and mode of surgery. Results: The mean POSSUM score was 23.9. The mean FIS was 13.95 (12-22), and the mean IQ was 9.4 (7-16). The distribution of patients was performed for BMI. The group with BMI 35-45 (n = 4 patients) had a mean POSSUM score of 22.75, a mean FIS of 13.75, and a mean IQ of 9.0. The group with BMI >45 (n = 16 patients) had a mean POSSUM score of 24.18, a mean FIS of 14.62, and a mean IQ of 9.5. The morbidities were gastric fistula with peritonitis and deep venous thrombosis. The two complications had similar POSSUM scores with different BMIs. No mortality was observed. Conclusions: According to this experience, the POSSUM scoring system appears to provide an indicator of minor risk of morbidity and mortality in bariatric surgery with vertical banded gastroplasty.

Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap

BackgroundPublished long-term outcomes of oncoplastic breast-conserving surgery are scarce and, specifically, aesthetic outcomes assessed with an objective method have not previously been published.MethodsA cohort of 41 patients treated with a quadrantectomny and immediate reconstruction using a myocutaneous latissimus dorsi flap were analyzed and their aesthetic outcomes were evaluated objectively by BCCT.core software.ResultsAt the end of a 58-month follow-up from the date of initial diagnosis, one patient (2.4%) developed an ipsilateral recurrence, six patients developed distant metastases and three patients died (7.3%) without ipsilateral recurrence, one of them presenting hepatic metastases at the time of the initial diagnosis. We were able to evaluate aesthetic results in 23 patients, 3 assessed as excellent, 12 good and 8 fair.ConclusionThis oncoplastic volume replacement technique obtained a good local control and satisfactory and stable aesthetic results which have maintained unchanged after a long period of time.

Giant hamartoma of the breast treated by the mammaplasty approach

A 29-year-old Arabic woman without risk factors for breast cancer had experienced a slow and progressive enlargement of her left breast without other associated symptoms for approximately 7 years. Physical examination showed a considerable breast asymmetry, the left breast being bigger and the palpation of which showed a diffuse sensation of increased breast consistency due to a mobile mass situated in the middle of the breast. Mammography showed a well-circumscribed mass 14 cm in diameter, situated in the centre of the breast and occupying it entirely. The diagnosis of breast hamartoma was carried out by a core-needle biopsy. Surgical treatment, excision of the tumour and reconstruction of the breast were carried out using a mammaplasty approach with a Wise pattern (T-inverted) and two pedicles: lateral superior to displace the nipple areola complex (NAC) and an inferior one to increase the breast projection. A well-encapsulated tumour, with a white–grey capsule rich in capillary vessel, smooth, ovoid-shaped, measuring 15 cm and weighing 535 g was easily dissected from the normal breast tissue and removed; its pathological examination confirmed the previous diagnosis of hamartoma. Figure 1 shows the preoperative and postoperative appearances of the patient, lateral and cranial mammography and the aspect of the surgical specimen. Simple enucleation of hamartoma and secondary expansion of the breast tissue are often sufficient to restore breast symmetry but, sometimes, when the hamartoma has caused considerable enlargement of the breast for a long period of time, surgical treatment using a mammaplasty technique offers clear advantages.1,2 This surgical approach facilitates the removal of the tumour, the remodelling of the breast and the NAC relocation. Mammaplasty techniques are very useful tools for the surgical treatment of breast tumours, benign or malignant.3 We consider that these ought to be incorporated into the surgical training of the ‘breast surgeon’ responsible for the surgical treatment of the breast tumours. 216 LETTERS TO THE EDITOR

Malignant Cystosarcoma Phyllodes of the Breast Treated with Oncoplastic Conservative Surgery

M alignant cystosarcoma phyllodes of the breast is a rare fibroepithelial tumor. Breast-conserving surgery with wide local excision, whenever cosmetically results are feasible, is the mainstay of surgical treatment. Axillary lymphadenectomy is not necessary. The margin of surgical excision is an independent prognostic factor in local recurrence (it is recommended that at least 1–2 cm be removed). We report a 22-year-old woman with cystosarcoma phyllodes, who had a previous incomplete excision after a misdiagnosis of fibroadenoma that was treated with oncoplastic conservative surgery (partial mastectomy and reconstruction with a lattismus dorsi flap). This technique allowed the removal of the residual tumor, surgical bed, and scar located in the upper quadrants in a medium-size breast, with good cosmetic results (Figs 1 and 2). Pathology of the surgical specimen showed free macroscopic and microscopic margins. In this case, the application of an oncoplastic surgery technique avoided a total mastectomy in a young patient.

Treatment of symptomatic macromastia in a breast unit.

BackgroundPatients suffering from symptomatic macromastia are usually underserved, as they have to put up with very long waiting lists and are usually selected under restrictive criteria. The Oncoplastic Breast Surgery subspeciality requires a cross-specialty training, which is difficult, in particular, for trainees who have a background in general surgery, and not easily available. The introduction of reduction mammaplasty into a Breast Cancer Unit as treatment for symptomatic macromastia could have a synergic effect, making the scarce therapeutic offer at present available to these patients, who are usually treated in Plastic Departments, somewhat larger, and accelerating the uptake of oncoplastic training as a whole and, specifically, the oncoplastic breast conserving procedures based on the reduction mammaplasty techniques such as displacement conservative techniques and onco-therapeutic mammaplasty. This is a retrospective study analyzing the outcome of reduction mammaplasty for symptomatic macromastia in our Breast Cancer Unit.MethodsA cohort study of 56 patients who underwent bilateral reduction mammaplasty at our Breast Unit between 2005 and 2009 were evaluated; morbidity and patient satisfaction were considered as end points. Data were collected by reviewing medical records and interviewing patients.ResultsEight patients (14.28%) presented complications in the early postoperative period, two of them being reoperated on. The physical symptoms disappeared or significantly improved in 88% of patients and the degree of satisfaction with the care process and with the overall outcome were really high.ConclusionOur experience of the introduction of reduction mammaplasty in our Breast Cancer Unit has given good results, enabling us to learn the use of different reduction mammaplasty techniques using several pedicles which made it posssible to perform oncoplastic breast conserving surgery. In our opinion, this management policy could bring clear advantages both to patients (large-breasted and those with a breast cancer) and surgeons.