Glove and instrument changing to prevent tumour seeding in cancer surgery: a survey of surgeons' beliefs and practices

"One blade, two cuts?" A multidisciplinary survey investigating practice variability of scalpel blade change for simultaneous excision of multiple skin lesions in the same patient

BACKGROUND

Skin cancer incidence increases globally, requiring effective preventive measures and evidence-based treatment strategies. Current guidelines advocate for surgical excision as a first-line treatment for most early skin cancers. The study investigated practices regarding changing scalpel blades when excising multiple skin lesions in the same patient during the same visit (CSB) and explored how beliefs about iatrogenic seeding influence individual norms of practice.

METHODS

A multidisciplinary survey was conducted among 173 medical specialists involved in skin cancer care. Participants provided demographic information, years of experience, and practices regarding CSB in four clinical scenarios (first excised tumor: basal cell carcinoma, squamous cell carcinoma, melanoma suspect, and evident melanoma). Practice variations based on specialty, experience, and beliefs about seeding risk were statistically assessed.

RESULTS

Surgeons exhibited a significantly higher tendency to change blades compared to non-surgeons across all diagnoses. Iatrogenic seeding (56.52%) and clinical training (18.84%) were the main reasons provided for CSB. Beliefs about seeding risk did not differ significantly between specialties.

CONCLUSIONS

Although the practice of CSB lacks strong scientific rationale, the approach to this practice significantly varies among different medical specialties. Healthcare professionals should critically evaluate and standardize evidence-based practices to ensure optimal patient care and mitigate potential harm.

Intra-flap recurrence of an oral squamous cell carcinoma after curative resection and reconstruction with a free flap

Intra-flap recurrence after reconstruction is a possible complication in oral squamous cell carcinoma (OSCC) after curative resection and reconstruction with a free flap.

Abstract

This case report describes an intra-flap recurrence after tumor resection and reconstruction with a latissimus dorsi flap due to OSCC. We report a 58-year-old female patient who underwent curative resection of a squamous cell carcinoma in the oral cavity and submental area and reconstruction with a latissimus dorsi free flap. Thirteen months after the operation, the patient presented with lung metastases and, 22 months after the operation, a metastatic lesion in the flap's central area with no sign of recurrence in the primary resection site occurred. The patient died 25 months after the initial operation due to the rapid progression of the disease and further distant metastases. To our knowledge, similar cases do not exist in the literature. This is the first reported case of intra-flap metastasis after surgical treatment of OSCC.

The free bilamellar autograft (FBA) procedure: A comprehensive case series of an alternative surgical approach to reconstruction of large eyelid defects

Purpose

The free bilamellar autograft (FBA) procedure involves harvesting a free, full-thickness section of eyelid tissue from one of the patient's healthy eyelids to reconstruct a large defect of the involved eyelid. No vascular augmentation is employed. The purpose of this study was to determine the structural and cosmetic results of this procedure.

Methods

A case series was performed, looking at patients who underwent the FBA procedure for large, full-thickness eyelid defects (>50% eyelid length) between 2009 and 2020 at a single oculoplastic surgical centre. Basal cell carcinomas most frequently met criteria for the procedure. OHSN-REB waived ethics approval. All surgeries were performed by one surgeon. A single operation, with surgical steps reported in detail, was completed with follow-up documentation at ideally 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year. The mean follow-up period was 28 months.

Results

Thirty-one patients (17 males, 14 females, mean age 78-years-old) were included in the case series. Comorbidities included diabetes and smoking. Most patients had known basal cell carcinomas removed from the upper or lower eyelid. The mean widths of the recipient and donor sites were 18.8 and 11.5 mm, respectively. All 31 FBA surgeries resulted in structurally functional, cosmetically pleasing, and viable eyelids. Six patients developed minor graft dehiscence, 3 developed an ectropion, and 1 developed mild superficial graft necrosis secondary to frostbite, which fully recovered. Three healing phases were identified.

Conclusion

This case series adds to the currently sparse data on the free bilamellar autograft procedure. The surgical technique is clearly articulated and illustrated. The FBA procedure is a simple and efficient alternative to current surgical techniques in the reconstruction of full-thickness upper and lower eyelid defects. The FBA provides functional and cosmetic success, despite the absence of an intact blood supply, with decreased operative time and faster recovery.

Glove and instrument changing to prevent bacterial contamination in infected wound debridement and closure procedures: A prospective observational study

Many surgeons use a single table of instruments for both excisional debridement and coverage/closure of infected wounds. This study investigates the effectiveness of a two-table set-up of sterile instruments, in addition to glove exchange, to reduce instrument cross-contamination during these procedures. This is a prospective, single-site, institutional review board-approved observational study of surgical debridements of infected wounds over a 17-month period. Two separate sterile surgical tables were used for each case: Table A for initial wound debridement (debridement set-up) and Table B for wound coverage/closure (clean set-up). Swabs of each table and its respective instruments were taken after debridement but prior to coverage/closure. The primary outcome of interest was bacterial growth at 48 hours. There were 72 surgical cases included in this study. Culture results of Table A demonstrated bacterial growth in 23 of 72 (32%) cases at 48 hours compared with 5of 72 (7%) from Table B (P = .001). These data suggest that there is significant bacterial contamination of surgical instruments used for debridement of infected wounds. Use of a two-table set-up reduced instrument cross-contamination by 78%, suggesting avoidable re-contamination of the wound.

The Risk of Tumor Contamination Associated With Thoracic Instrumentation in Patients With Osteosarcoma: 2 Case Reports and a Literature Review

Orthopedic surgeons are well aware of tumor contamination at the site of initial biopsy in osteosarcoma. However, tumor contamination in patients with osteosarcoma associated with thoracic instrumentation is not well described. The authors summarize 2 reported cases in addition to the 2 cases at their institution of this phenomenon. Knowledge of tumor contamination and preventative measures against tumor contamination is sparse in the literature, especially pertaining to patients with osteosarcoma undergoing thoracic instrumentation. In this report, the authors hope to increase awareness of these cases and suggest preventative measures to mitigate against tumor contamination in patients with osteosarcoma. The authors report that the median time between thoracic instrumentation and the visible detection of tumor migration to local sites was 5 months. They conclude that tumor contamination associated with thoracic instrumentation is characterized by patients with multiple sites of relapse and aggressive, fatal disease.

Subcutaneous seeding following surgical excision of an intracranial meningioma in a cat

Traditionally patient owners express their concerns that surgical or diagnostic procedures on a tumor may induce metastasis. In pets, this has been documented in only very rare occasions, e. g. needle path metastases after diagnostic fine needle biopsies of urinary bladder or prostatic tumors. Here, we describe a case of subcutaneous seeding of a feline intracranial grade 1 meningioma 6 months after surgical resection. A 10-year-old male neutered domestic shorthaired cat with typical neurological signs was diagnosed with an extra-axial contrast enhancing mass in the dorsal frontotemporal lobes using magnetic resonance imaging (MRI). Transfronto-parietal bone craniotomy was performed and the 24 × 19 × 22 mm large tumor was largely removed. Tumor recurrence after 12 months resulted in a second surgical tumor removal. In addition, 2 subcutaneous masses of 10 × 4 × 4 mm in size were removed at the site of the original surgical site which were fully separated from the recurring meningeal tumor by the intact frontal bone. Histology and immunohistochemistry suggested the same tumor growth in all 4 masses. Most likely the tumor seeding had been caused during the first surgery. After all, the risk of surgical seeding of a benign tumor seems very low.

Implantation of Squamous Cell Carcinoma in a Free Flap Donor Site

INTRODUCTION

It is well known that malignant cells can be implanted at distant donor sites due to iatrogenic surgical contamination. Only a small number of reports, however, have been published describing this.

CASE PRESENTATION

We present a case of oral cavity Squamous Cell Carcinoma (SCC) reconstructed with a radial forearm free flap in which SCC developed in the subcutaneous tissues beneath the donor incision site 6 months after surgery.

MANAGEMENT

The implanted tumor was excised and the field was subsequently treated with radiation. The patient remains disease-free on follow-up.

DISCUSSION

We present the second report of tumor implanted in a free flap donor site. Additionally, we discuss the risks of tumor implantation, review the literature, and make recommendations to avoid this complication.

Iatrogenic Implantation of Cancer Cells During Surgery

In the late 1800s, the concept of iatrogenic implantation of cancer cells during surgery was put forth. The most dramatic example is a recurrence in a donor graft site, which is often distant to the primary site of excision. This eliminates the possibility of incomplete removal as the etiology of recurrence. However, in addition to direct transplantation to the graft site via gloves or instruments, several other possibilities exist, including de novo lesions of squamous cell carcinoma in the graft, as well as systemic metastases. This article reviews 15 published case reports of cancer recurrence in graft donor sites in which the authors considered seeding via gloves or instruments. Viewing these cases in the context of a 2018 study demonstrates the varying opinions of surgeons on the possibility of cancer seeding. This article strongly advises the changing of gloves and instruments following resection of any suspicious or established cancerous tumors.