Sentinel lymph node biopsy in breast cancer: an analysis of the maximum number of nodes requiring excision

Sentinel lymph node biopsy (SNB) is now the standard of care in assessment of patients with clinically staged T1-2, N0 breast cancers. This study investigates whether there is a maximum number of sentinel lymph nodes (SLN) that need to be excised without compromising the false-negative (FN) rate of this procedure. Data were prospectively collected for 319 patients undergoing SNB between February 2001 and December 2006 at our institution. This data were analysed, both in terms of the order of SLN retrieval and relative isotope counts of the SLNs, in order to determine the maximum number of SLNs that need to be retrieved without increasing the FN rate. Furthermore, we investigated the relationship between SLN blue dye concentration and the presence of SLN metastases. The SLN identification rate was 97% with no false-negative cases amongst patients undergoing simultaneous axillary clearance historically during technique validation. In patients with SLN metastases, excision of the first 4 SLNs encountered results in the identification of a metastatic SLN in all cases. Although the majority (86%) of SNB metastases are in the hottest node, the SLN containing the metastasis is in the first 4 hottest nodes in 99% of patients with nodal metastases. The remaining 1% of SLN metastases were identified by blue dye. There was no statistically significant association between the SLN blue dye concentration and the presence of SLN metastases. A policy to remove a maximum of four blue and/or hot SLNs along with any palpably abnormal lymph nodes does not result in an increased false-negative rate of detection of SLN metastases.

Duplex-defined spatial anatomy of the saphenopopliteal junction

Background: Failure to disconnect the saphenopopliteal junction (SPJ) can occur in spite of duplex marking prior to operation indicating that more information on the short saphenous vein (SSV) termination in addition to the duplex mark is necessary to improve operative outcomes. The aim of this study was to establish the three-dimensional anatomy of the SSV termination to aid in improving operative localization of the SSV and SPJ.

Method: A prospective colour duplex study of 50 consecutive primary refluxing SSV was undertaken. The spatial orientation of the SSV termination in terms of location within the popliteal fossa and depth from the skin was determined.

Results: The SPJ was located in most cases (98%) in the upper lateral quadrant of the popliteal fossa. The median depth of the SPJ beneath the skin was 2.9 (1.6–5.2) cm. The SSV leaves the midline at a distance of approximately 5 (0–8) cm below the midpoint of the popliteal fossa and travels laterally towards the SPJ. It stays close to the skin and makes the descent into the fossa at 2–3 cm below the SPJ. The mean rate of descent between the SPJ and 2 cm below it was 7.0 (1–12) mm/cm, while that between 2 and 4 cm below the SPJ was only 2.3 (0–7) mm/cm.

Conclusion: The SPJ lies at a variable depth beneath the skin in the upper outer quadrant of the popliteal fossa. Locating the incision 2 cm below and medial to the SPJ, where the SSV lies relatively superficial and at a less variable depth, will allow easier identification of the SSV and thus easier localization of the SPJ.

Do specialist registrars fail smokers?

INTRODUCTION

Medical and surgical SpRs were interviewed to determine what efforts they make to stop patients smoking.

METHODS

Telephone interview of 53 SpRs in the Oxford region.

RESULTS

The majority regularly asked whether patients smoked, few did anything about it. Surgical SpRs were less likely than medical SpRs to advise patients to stop, discuss smoking-related health problems, discuss the benefits of quitting or advise nicotine replacement therapy. Few SpRs had been trained to counsel smokers and less than half felt that their input helped patients to stop.

CONCLUSION

Medical education is lacking in teaching students and junior doctors how to help patients stop smoking.

Critical appraisal of femorofemoral crossover grafts

Background

The aim of this study was to determine how often femorofemoral crossover grafting for critical ischaemia or intermittent claudication gives an ideal result. An ideal result is an uncomplicated operation with primary wound healing, relief of ischaemic symptoms without recurrence and no need for further intervention.

Methods

All patients undergoing primary femorofemoral crossover grafting between January 1988 and December 2003 were studied.

Results

Some 144 operations were analysed; 51 patients had critical ischaemia and 93 claudication. There was one postoperative death (0·7 per cent). Complications occurred within 30 days in 32 patients (22·2 per cent), including graft occlusion in three (2·1 per cent); six patients (4·2 per cent) required early reoperation. Primary patency for patients with critical ischaemia was 88, 82 and 74 per cent at 1, 3 and 5 years respectively. Respective figures for those who presented with claudication were 93, 92 and 90 per cent (P = 0·034). Late symptoms included graft occlusion (20 patients), disease progression (25), ongoing ulceration (six), graft infection (nine), false aneurysm formation (two) and late donor-site stenosis (two).

Conclusion

When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

MRSA in lower limb amputation and the role of antibiotic prophylaxis

AIM

Methicillin Resistant Staphylococcus Aureus (MRSA) colonisation is reported in 3-20% of vascular patients. Many develop infective complications. MRSA is associated with poor prognosis. Aim of the study is to assess MRSA in lower limb amputation and efficacy of antibiotic prophylaxis.

METHODS

Prospective study of lower limb amputation. MRSA screen and wound swabs were taken at operation. Antibiotic prophylaxis included teicoplanin (400 mg) 1 dose at operation.

RESULTS

Twenty-five patients underwent 33 primary amputations. At operation 15 legs (45%) were colonised with MRSA and 18 legs (58%) had active wound infection; MRSA (4) and other (14). Following surgery 3 patients died. Twenty-two legs (76%) had primary healing. Infection developed in 7 stumps (24%), MRSA (5) and Pseudomonas (2). Stump infection increased time to wound healing (p<0.0001). MRSA stump infection increased revision amputation (p=0.009) and duration of hospital stay (p<0.0074). MRSA wound infection at operation increased the risk of MRSA stump infection (p=0.007). Non-MRSA wound infection at operation was not associated with a worse outcome. No patient colonised with MRSA at operation developed postoperative MRSA stump infection.

CONCLUSIONS

MRSA is more prevalent that previously reported. MRSA infection has a poor prognosis. Prophylaxis may be effective for patients colonised with MRSA.

Double-blind trial to compare ampicillin, cephalexin, co-trimoxazole, and trimethoprim in treatment of urinary infection

In order to test their value in urinary infection a double-blind trial was carried out using ampicillin, cephalexin, trimethoprim-sulphamethoxazole (co-trimoxazole), and trimethoprim. Eighty-three courses of treatment were given to hospital patients, 149 to pregnant women, and 107 to patients with dysuria and frequency seen in domiciliary practice. Thus infections of varying severity in defined groups of patients caused by organisms with different antibiotic sensitivities were treated.Analysis of the overall results (339 courses) was compared with those from the individual groups and considerable variation in response was found. In domiciliary infections and bacteriuria in pregnancy trimethoprim alone proved to be at least as effective as the other three compounds and caused fewer than half the number of side effects. In the hospital patients co-trimoxazole was superior to trimethoprim.The overall results for ampicillin and cephalexin were similar although cephalexin proved to be inferior in treating symptomatic domiciliary infections.