J. M. Dixon

Diagnostic delay in breast cancer

Delay in the diagnosis of breast cancer has important clinical and medicolegal implications. This study assessed the frequency, causes and effects of delay in the diagnosis of breast cancer in a specialist breast unit.

Colour doppler studies of axillary node metastases in breast carcinoma

Colour Doppler scans were carried out on 80 patients with breast carcinoma. Both the tumour and the lower axilla were scanned in all 80 patients. Seventy-five patients subsequently underwent axillary lymph node dissection and histological examination. The sensitivity of colour Doppler scanning for axillary node involvement was 70%, with a specificity of 98% and a positive predictive value of 96%.

Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin

Low molecular weight heparin (LMWH) is used in preference to unfractionated heparin (UFH) for the prevention of postoperative thromboembolism in many UK surgical units. There are, however, conflicting reports on the relative risk of significant bleeding in surgical patients, and no data exist in the literature for patients undergoing breast surgery.

Letter: treatment of loculated lactational breast abscess with a vacuum biopsy system (Br J Surg 2005; 92: 1225-1226)

that a recurrence rate comparable to Lichtenstein repair can be achieved. In our study we had no obvious explanation why the re-operation rate after laparoscopic repair of primary bilateral hernias was higher than after Lichtenstein repair. Despite a fairly small annual work volume per hospital, however, the nationwide analysis clearly shows that outcome after laparoscopic repair of unilateral hernias as well as recurrent hernias was comparable to outcome after Lichtenstein repair. We are left with no other option but to speculate whether a larger experience of laparoscopic repair of bilateral hernias would have produced outcomes comparable to Lichtenstein repair. P. Wara, M. Bay-Nielsen, P. Juul, J. Bendix and H. Kehlet Department of Surgery, Århus University Hospital, Ved Stranden 141, Århus, 8250 Egå, Denmark DOI: 10.1002/bjs.5310

Multicentre evaluation of intraoperative molecular analysis of sentinel lymph nodes in breast carcinoma (Br J Surg 2011; 98: 527-535).

Sir We read with great interest the article by Hilvering and colleagues about the use of combined preincisional and intraperitoneal administration of levobupivacaine to prevent postoperative pain after laparoscopic cholecystectomy. We believe, however, that several factors must be taken into consideration before drawing formal conclusions from the results presented. We totally agree with the authors when they stated that postoperative complications should not be related to possible side-effects of levobupivacaine. We are concerned about the higher incidence of complications in the treatment group that was close to statistical significance (P = 0·056 when pooling all complications). The difference reached significance when considering possible complications in the patient not included in analysis (P = 0·029, Fisher’s exact test). One may speculate that a twofold higher complication rate in the levobupivacaine group might have influenced the results. Bile and blood are well documented stimuli of chemical peritoneal irritation and inflammation that may influence pathophysiological pain mechanisms1 – 4. It might explain unexpected results and discrepancies with available data from previously published studies. Data on intraoperative opioid consumption are also surprising. The study protocol anticipated infusion of 1 μg per kg per min remifentanil. This was clearly below the mean doses reported in the two study groups. Excessive remifentanil administration might have exposed patients to opioidinduced hyperalgesia5, leading to a difficult interpretation. The authors should be congratulated for their valuable contribution to improving knowledge in enhanced recovery programmes. Nevertheless, we believe that both surgeons and anaesthetists should interpret the results presented in the light of the study limitations. E. Futier, A. Petit and D. Pezet University Hospital of Clermont-Ferrand, Clermont-Ferrand, France (e-mail: efutier@chu-clermontferrand.fr) DOI: 10.1002/bjs.7633

Authors' reply: Use of enoxaparin results in more haemorrhagic complications after breast surgery than unfractionated heparin (Br J Surg 2008; 95: 834–836)

embolism (RR 0·60; 95 per cent c.i. 0·22–1·64), minor bleeding (RR 0·88; 95 per cent c.i. 0·47–1·66), or major bleeding (RR 0·95; 95 per cent c.i. 0·51–1·77)2. Finally, although it is widely accepted that thrombosis in cancer patients might predominantly be initiated by malignancy-induced hypercoagulability due to elevated preoperative levels of D-dimer, fibrinogen, and plasminogen activator inhibitor activity it is unclear whether breast cancer patients warrant prophylaxis due to the lower risk of thrombosis because of early mobilization and the higher risk of haemorrhage due to the increased vascularity of the gland and the subsequent deadspace that is surgically created3. I look forward to your thoughts on these matters. M. Barry Department of Surgery, Connolly Memorial Hospital, Blanchardstown, Dublin 15, Ireland DOI: 10.1002/bjs.6421

117 O - Axillary node sampling in breast cancer: an assessment of its efficacy

Some surgeons have been unable to dissect out 4 separate nodes from the axilla. Reports have also indicated that as increasing numbers of nodes in the lower axilla are sampled, so the chance of identifying involved nodes increases. 392 patients undergoing consecutive axillary node sampling performed by all grades of surgeons have been studied. The number of nodes removed ranged from 0–12 and only 19 patients had less than 3 nodes in the specimen submitted for pathology (Table). The mean number of nodes sampled was 4.8 with a standard error (SE) of 0.16 and the mean was 4. The percentage of patients who were node positive did not increase significantly as the number of nodes increased (Table). Mean number of nodes sampled when axillary node negative was 4.6 (SE 0.10) and 4.89 (SE 0.24) When nodes were involved. These data show that it is possible to dissect out 4 axillary nodes consistently and the chances of identifying involved nodes does not increase significantly as the number of nodes sampled increases. Nodes 0 1 2 3 4 5 6 7 8 9 >9 Found No Pts involved 2 9 8 50 148 101 33 10 8 8 15 Nodes (%) 0 33 38 28 21 22 18 30 13 38 47