'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Symmetrisation procedures in breast reconstruction patients constitute a rising workload in our DGH

INTRODUCTION

In breast cancer patients undergoing reconstructive surgery, achieving symmetry is of considerable importance. The aim of our study was to identify the proportion of breast cancer patients undergoing reconstructive surgery requiring contralateral symmetrisation procedures.

PATIENTS AND METHODS

This is a retrospective review of consecutive patients undergoing reconstructive procedures following cancer surgery from April 2005 to April 2012.

RESULTS

One hundred and fifty three patients had symmetrisation procedure of the opposite side during this period. The median age was 53 years (22-79). Reduction mammoplasty was the commonest procedure (94 patients), followed by mastopexy (34 patients) and augmentation mammoplasty (25 patients). Overall, it represent approximately one third of (153/489; 31.2%) of all the major reconstruction procedures in this unit.

CONCLUSION

Almost half the number of patients (153/336) undergoing breast reconstruction as a part of breast cancer surgery had a symmetrisation procedure performed on the opposite side which constitutes a significant reconstructive workload in our unit. Consideration should be given to the above when planning departmental work force and training.

Ventral hernia repair: a study of current practice

Ventral wall hernias are common; despite this, there are no guidelines on the best surgical management. The aim of this study was to examine the types of repair in use for abdominal wall hernias in the West of Scotland over a 3-month period. Data were gathered on 120 patients. There were 60 incisional, 32 umbilical, and 28 epigastric hernias. The main indication for repair was pain (78%), while 12 patients (10%), presented acutely with incarceration or strangulation. The most common method of repair was sutured (55%), followed by mesh (29%) and Mayo repair (16%). There was no correlation between use of mesh and hernia size or whether repair was for a recurrent hernia. Surgical practice varies widely in the repair of ventral wall hernias. Clinical trials are required to establish the best method of repair for this common condition.

Factors involved in abdominal wall closure and subsequent incisional hernia

Incisional hernia is a frequent complication of abdominal wall closure with a reported incidence of between 5% and 15% following vertical midline incisions at one-year follow-up. Evidence from randomised clinical trials and meta-analysis indicate that a continuous running non-absorbable or slowly absorbed suture such as polydioxanone is the method of choice for abdominal wall closure. Continuous polydioxanone has a similar incisional hernia rate to its non-absorbable counterparts but causes less chronic pain and wound sinuses. Evidence from randomised clinical trials indicates that a lateral paramedian incision is associated with a lower incidence of incisional hernia when compared with other abdominal incisions. Transverse abdominal incisions have no advantage over midline incisions in reducing incisional hernia rate. Although experimental and clinical evidence indicate that a greater number of stitches with a suture length to wound ratio of at least 4:1 is associated with a lower incidence of incisional hernia, there is no evidence from randomised clinical trials to support this. Intuitively one may think that putting as little tension as possible on the closure is important, but there is no evidence for this. Clinical trials evaluating these factors would be difficult to undertake making it important that surgeons continue to audit incisional hernia rates following abdominal closure.

Outcome of patients with severe chronic pain following repair of groin hernia

BACKGROUND

Chronic pain is the most serious long-term complication that can occur after repair of a groin hernia. The aim of this study was to assess the outcome of patients who report severe or very severe pain 3 months after groin hernia repair.

METHODS

This was a population-based study of all patients who underwent repair of a groin hernia between April 1998 and March 1999 in Scotland. All received a postal questionnaire 3 months after hernia repair and those who reported severe or very severe pain at the operation site were asked to complete a further questionnaire 2.5 years later. The main outcome measure included the number of patients with persistent pain and the effect of pain on daily activities and quality of life.

RESULTS

Of 5506 patients who underwent repair of a groin hernia, 4062 (74 per cent) returned the first questionnaire and 125 (3 per cent) reported severe or very severe pain. Eight-six (72 per cent) of 120 patients (five had died or could not be contacted at the original address) replied to the second questionnaire; 61 (71 per cent) still reported pain, which was severe or very severe pain in 22 (26 per cent) and mild or very mild in 39 (45 per cent). Twenty-nine (48 per cent) sought further medical help from their general practitioner or surgeon. Nine (15 per cent) attended a pain clinic while five (8 per cent) had further surgery. Chronic pain had significant effects (P < 0.001) on all daily activities including walking, work, sleep, relationships with other people, mood and general enjoyment of life.

CONCLUSION

Chronic pain persists in most patients who report severe or very severe pain at 3 months after hernia repair, and has a significant effect on the patients' daily activities and quality of life.

Antigen receptors on immature, but not mature, B and T cells are coupled to cytosolic phospholipase A2 activation: expression and activation of cytosolic phospholipase A2 correlate with lymphocyte maturation

The Ag receptors on mature B and T cells are not coupled to the activation of cytosolic phospholipase A2 (cPLA2) and arachidonic acid release. Moreover, phorbol esters such as PMA, which can activate cPLA2 via mitogen-activated protein (MAP) kinase in most cell types, also failed to induce the release of arachidonate from mature cells, suggesting that the cPLA2 pathway may not be functional in mature lymphocytes. Interestingly, Western blot analysis revealed that cPLA2, which had previously been thought to be expressed ubiquitously, is not expressed in mature B or T cells and that cytosolic phospholipase A2 expression could not be up-regulated in lymphocytes following culture with a range of cytokines most likely to be involved in an immune response such as IL-1 alpha, IL-3, or TNF-alpha. In contrast, cPLA2 was shown to be expressed and activated in thymocytes and immature B cells under conditions in which ligation of the Ag receptors led to growth arrest and/or apoptosis. Taken together, these data suggest that cPLA2 does not play a role in Ag receptor-mediated lymphocyte activation, but may be involved in the molecular mechanisms underlying lymphocyte maturation and/or self tolerance by clonal deletion.

Antigen receptors on immature, but not mature, B and T cells are coupled to cytosolic phospholipase A2 activation: expression and activation of cytosolic phospholipase A2 correlate with lymphocyte maturation

The Ag receptors on mature B and T cells are not coupled to the activation of cytosolic phospholipase A2 (cPLA2) and arachidonic acid release. Moreover, phorbol esters such as PMA, which can activate cPLA2 via mitogen-activated protein (MAP) kinase in most cell types, also failed to induce the release of arachidonate from mature cells, suggesting that the cPLA2 pathway may not be functional in mature lymphocytes. Interestingly, Western blot analysis revealed that cPLA2, which had previously been thought to be expressed ubiquitously, is not expressed in mature B or T cells and that cytosolic phospholipase A2 expression could not be up-regulated in lymphocytes following culture with a range of cytokines most likely to be involved in an immune response such as IL-1 alpha, IL-3, or TNF-alpha. In contrast, cPLA2 was shown to be expressed and activated in thymocytes and immature B cells under conditions in which ligation of the Ag receptors led to growth arrest and/or apoptosis. Taken together, these data suggest that cPLA2 does not play a role in Ag receptor-mediated lymphocyte activation, but may be involved in the molecular mechanisms underlying lymphocyte maturation and/or self tolerance by clonal deletion.