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The impact of special histological types (ST) in triple-negative breast cancer (TNBC) and its association with overall outcome has gained increasing relevance as survival has been linked to specific histological TNBC subtypes. We evaluated the clinicopathological and survival data of 598 patients with 613 TNBCs, including 464 TNBCs of no special type (NST) and 149 TNBCs ST (low-grade, n = 12, 8.1%; high-grade, n = 112, 75.2%; apocrine and androgen receptor-positive [APO AR], n = 25, 16.8%). Patients with low-grade TNBC ST and TNBC ST APO AR were significantly older (P < 0.001) and had a lower Ki67 index (P < 0.001) than those with TNBC NST. Patients with high-grade TNBC ST were significantly older (P = 0.006) and had poorer pathological responses to neoadjuvant chemotherapy (NAC) (P < 0.001) than those with TNBC NST. Significant survival differences were observed between low-grade TNBC ST, TNBC ST APO AR, high-grade TNBC ST, and TNBC NST in the entire study group (DFS, P = 0.002; DDFS, P = 0.001) and in the non-NAC subgroup (OS, P = 0.034; DFS, P = 0.001; DDFS, P < 0.001). Patients with low-grade TNBC ST had the best survival outcomes. Patients with high-grade TNBC ST showed significantly worse outcomes than those with TNBC NST (entire study group: OS, P = 0.049; DFS, P < 0.001; DDFS, P = 0.001; non-NAC subgroup: OS, P = 0.014; DFS, P < 0.001; DDFS, P < 0.001). We conclude that prognostic stratification of TNBC ST is ultimately important for optimizing the therapeutic management of patients with these rare tumor entities., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Aim: Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario., Methods: A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology., Results: The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR., Conclusions: The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Recent data suggest that margins ≥2 mm after breast-conserving surgery may improve local control in invasive breast cancer (BC). By allowing large resection volumes, oncoplastic breast-conserving surgery (OBCII; Clough level II/Tübingen 5-6) may achieve better local control than conventional breast conserving surgery (BCS; Tübingen 1-2) or oncoplastic breast conservation with low resection volumes (OBCI; Clough level I/Tübingen 3-4)., Methods: Data from consecutive high-risk BC patients treated in 15 centers from the Oncoplastic Breast Consortium (OPBC) network, between January 2010 and December 2013, were retrospectively reviewed., Results: A total of 3,177 women were included, 30% of whom were treated with OBC (OBCI n = 663; OBCII n = 297). The BCS/OBCI group had significantly smaller tumors and smaller resection margins compared with OBCII (pT1: 50% vs. 37%, p = 0.002; proportion with margin <1 mm: 17% vs. 6%, p < 0.001). There were significantly more re-excisions due to R1 ("ink on tumor") in the BCS/OBCI compared with the OBCII group (11% vs. 7%, p = 0.049). Univariate and multivariable regression analysis adjusted for tumor biology, tumor size, radiotherapy, and systemic treatment demonstrated no differences in local, regional, or distant recurrence-free or overall survival between the two groups., Conclusions: Large resection volumes in oncoplastic surgery increases the distance from cancer cells to the margin of the specimen and reduces reexcision rates significantly. With OBCII larger tumors are resected with similar local, regional and distant recurrence-free as well as overall survival rates as BCS/OBCI., (© 2021. The Author(s).)

Background Among patients with breast cancer undergoing neoadjuvant chemotherapy (NACT), the association between pathological complete remission (pCR) in the breast and clinical/pathological parameters is well established, whereas the association between these parameters and residual axillary involvement after NACT remains unclear. Methods Patients with clinically occult nodal metastases (i.e. negative by clinical assessment but positive by SLNB prior to NACT, i.e. Arm B of the SENTINA trial) were included in the presented analysis. All patients received a second sentinel lymph node biopsy (SLNB) and axillary dissection after NACT. Univariate and multivariate analyses were carried out to evaluate the association between clinical/pathological parameters and axillary involvement after NACT. Results Arm B of the SENTINA study contained 360 patients, 318 of which were evaluable for this analysis. After NACT, 71/318 (22.3%) patients had involved SLNs or non-SLNs after NACT. Overall, 71/318 (22.3%) patients achieved a pCR in the breast. Associations of extranodal spread, lack of multifocality and pCR in the breast with residual axillary burden were statistically significant. In a descriptive analysis including all patients with clinically negative axilla before NACT in the SENTINA trial 1.2% of triple negative (TN) patients and 0.5% of HER/2 positive patients had residual axillary disease in case of a breast pCR. Conclusions Patients in the SENTINA trial with clinically negative axilla and involved SLNs still carried a significant risk of nodal metastases after NACT. However, the risk of residual axillary burden was particularly low in TN and HER/2 positive tumors in case of a breast pCR., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: The ABCSG-28 trial compared primary surgery followed by systemic therapy versus primary systemic therapy without surgery in patients with de novo stage IV BC. The present report describes QoL results of this trial., Methods: Ninety patients with primary operable MBC were randomised to surgery of the primary tumor followed by systemic therapy or to primary systemic therapy without surgery. QoL analyses covering the results at baseline, 6,12,18 and 24 months follow up of 79 (88%) patients, was assessed with the EORTC QLQ-C30 and QLQ-BR23 questionnaires., Results: There were no statistically significant differences in any of the scales of the QLQ-C30 and QLQ-BR23 questionnaires between the two groups over the time. Baseline global health status and physical functioning were predictors for OS (patients with a higher score lived longer (p=0.0250, p=0.0225; p=0.0355, p=0.0355)). Global health status, social functioning scale, breast symptoms and future perspective were predictors for longer TTPd (p=0.0244; p=0.0140, p=0.020; p=0.0438, p=0.0123). Patients in both arms reported significant improvement on the emotional functioning scale. Cognitive functioning decreased over time in both groups. Younger women had clinically relevant better physical and sexual functioning scores (p=0.039 and 0.024)., Conclusion: Primary surgery does not improve nor alter QoL of patients with de novo stage IV BC. Global health status and physical functioning were predictors for OS and could be use as additional marker for prediction of OS and TTTd in patients with de novo stage IV BC., Trial Registration: The trial is registered on clinicaltrial.gov (NCT01015625, date of registration:18/11/2009).

Background: Conflicting evidence exists regarding the value of surgical resection of the primary in stage IV breast cancer patients., Objective: The prospective randomized phase III ABCSG-28 POSYTIVE trial evaluated median survival comparing primary surgery followed by systemic therapy to primary systemic therapy in de novo stage IV breast cancer., Methods: Between 2011 and 2015, 90 previously untreated stage IV breast cancer patients were randomly assigned to surgical resection of the primary tumor followed by systemic therapy (Arm A) or primary systemic therapy (Arm B) in Austria. Overall survival (OS) was defined as the primary study endpoint., Results: The trial was stopped early due to poor recruitment. Ninety patients (45 arm A, 45 arm B) were included; median follow-up was 37.5 months. Patients in the surgery arm had more cT3 breast cancer (22.2% vs 6.7%) and more cN2 staging (15.6% vs 4.4%). Both groups were well balanced with respect to the type of first-line systemic treatment. Median survival in arm A was 34.6 months, versus 54.8 months in the nonsurgery arm [hazard ratio (HR) 0.691, 95% confidence interval (95% CI) 0.358-1.333; P = 0.267]; time to distant progression was 13.9 months in the surgery arm and 29.0 months in the nonsurgery arm (HR 0.598, 95% CI 0.343-1.043; P = 0.0668)., Conclusion: The prospective phase III trial ABCSG-28 (POSYTIVE) could not demonstrate an OS benefit for surgical resection of the primary in breast cancer patients presenting with de novo stage IV disease.

Background: With the growing importance of neoadjuvant systemic therapy (NST) the assessment of post neoadjuvant axillary status is of increasing importance especially in patients who presented initially with suspicious nodes (cN1). This study aims to investigate the predictive value of palpation and axillary ultrasound of formerly cN1 patients following NST., Patients and Methods: The SENTINA trial (SENTinel NeoAdjuvant) is a 4-arm prospective multicenter study designed to evaluate the role of sentinel node biopsy (SLNB) in the context of neoadjuvant systemic treatment (NST) of breast cancer patients., Results: 1240 patients from 103 institutions entered the trial. 715 (arm C n = 592; arm D n = 123) patients, who presented initially cN1 underwent clinical evaluation of lymph node status following NST. Palpation alone demonstrated a sensitivity of 8.3%, specifity of 94.8% and a negative predictive value (NPV) of 46.6%. Ultrasound alone revealed a sensitivity of 23.9%, specificity 91.7%, and a NPV of 50.3%.The investigators combined classification (palpation and ultrasound) resulted in a sensitivity of 24.4%, specificity 91.4%, and a NPV of 50.3%. Investigators classified the axilla nodes as being unsuspicious (cN0) following NST in 592/715 patients; of them 298 (50.3%) were pN0, 151 (25.5%) had 1-2 histologically involved nodes and 143 (24.2%) had >2 histologically involved nodes., Conclusion: The diagnostic accuracy of ultrasound and palpation following NST is unacceptably low and additional tools for evaluation of the axillary lymph node status following NST are urgently needed., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Comparative studies on the use of meshes and acellular dermal matrices (ADM) in implant-based breast reconstruction (IBBR) have not yet been performed., Methods: This prospective, randomized, controlled, multicenter pilot study was performed at four Austrian breast cancer centers. Fifty patients with oncologic or prophylactic indication for mastectomy and IBBR were randomized to immediate IBBR with either an ADM (Protexa(®)) or a titanized mesh (TiLOOP(®) Bra). Complications, failed reconstruction, cosmetic outcome, patients' quality of life and the thickness of the overlying tissue were recorded immediately postoperatively and 3 and 6 months after surgery., Results: 48 patients participated in the study (Protexa(®) group: 23; TiLOOP(®) Bra group: 25 patients). The overall complication rate was 31.25% with similar rates in both groups (Protexa(®) group: 9 versus TiLOOP(®) Bra group: 6; p = 0.188). There was a higher incidence of severe complications leading to failed reconstructions with implant loss in the Protexa(®) group than in the TiLOOP(®) Bra group (7 versus 2; p < 0.0001). An inverted T-incision technique led to significantly more complications and reconstructive failure with Protexa(®) (p = 0.037, p = 0.012, respectively). There were no significant differences in patients' satisfaction with cosmetic results (p = 0.632), but surgeons and external specialists graded significantly better outcomes with TiLOOP(®) Bra (p = 0.034, p = 0.032)., Conclusion: This pilot study showed use of TiLOOP(®) Bra or Protexa(®) in IBBR is feasible leading to good cosmetic outcomes and high patient satisfaction. To validate the higher failure rates in the Protexa(®) group, data from a larger trial are required. NCT02562170., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: The optimum timing of sentinel-lymph-node biopsy for breast cancer patients treated with neoadjuvant chemotherapy is uncertain. The SENTINA (SENTinel NeoAdjuvant) study was designed to evaluate a specific algorithm for timing of a standardised sentinel-lymph-node biopsy procedure in patients who undergo neoadjuvant chemotherapy., Methods: SENTINA is a four-arm, prospective, multicentre cohort study undertaken at 103 institutions in Germany and Austria. Women with breast cancer who were scheduled for neoadjuvant chemotherapy were enrolled into the study. Patients with clinically node-negative disease (cN0) underwent sentinel-lymph-node biopsy before neoadjuvant chemotherapy (arm A). If the sentinel node was positive (pN1), a second sentinel-lymph-node biopsy procedure was done after neoadjuvant chemotherapy (arm B). Women with clinically node-positive disease (cN+) received neoadjuvant chemotherapy. Those who converted to clinically node-negative disease after chemotherapy (ycN0; arm C) were treated with sentinel-lymph-node biopsy and axillary dissection. Only patients whose clinical nodal status remained positive (ycN1) underwent axillary dissection without sentinel-lymph-node biopsy (arm D). The primary endpoint was accuracy (false-negative rate) of sentinel-lymph-node biopsy after neoadjuvant chemotherapy for patients who converted from cN1 to ycN0 disease during neoadjuvant chemotherapy (arm C). Secondary endpoints included comparison of the detection rate of sentinel-lymph-node biopsy before and after neoadjuvant chemotherapy, and also the false-negative rate and detection rate of sentinel-lymph-node biopsy after removal of the sentinel lymph node. Analyses were done according to treatment received (per protocol)., Findings: Of 1737 patients who received treatment, 1022 women underwent sentinel-lymph-node biopsy before neoadjuvant chemotherapy (arms A and B), with a detection rate of 99.1% (95% CI 98.3-99.6; 1013 of 1022). In patients who converted after neoadjuvant chemotherapy from cN+ to ycN0 (arm C), the detection rate was 80.1% (95% CI 76.6-83.2; 474 of 592) and false-negative rate was 14.2% (95% CI 9.9-19.4; 32 of 226). The false-negative rate was 24.3% (17 of 70) for women who had one node removed and 18.5% (10 of 54) for those who had two sentinel nodes removed (arm C). In patients who had a second sentinel-lymph-node biopsy procedure after neoadjuvant chemotherapy (arm B), the detection rate was 60.8% (95% CI 55.6-65.9; 219 of 360) and the false-negative rate was 51.6% (95% CI 38.7-64.2; 33 of 64)., Interpretation: Sentinel-lymph-node biopsy is a reliable diagnostic method before neoadjuvant chemotherapy. After systemic treatment or early sentinel-lymph-node biopsy, the procedure has a lower detection rate and a higher false-negative rate compared with sentinel-lymph-node biopsy done before neoadjuvant chemotherapy. These limitations should be considered if biopsy is planned after neoadjuvant chemotherapy., Funding: Brustkrebs Deutschland, German Society for Senology, German Breast Group., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The prognosis of breast cancer is most heavily influenced by the status of the axillary nodes. Until a few years ago, this knowledge was gained through radical axillary lymph node clearance. In the meantime, sentinel lymph node clearance has become an established part of the surgical treatment of breast cancer. With the development of this procedure, the morbidity caused by axillary dissection has been reduced significantly. Although comprehensive prospective, randomised data regarding the safe use of the sentinel concept are only now available, the focus currently, however, is on the question of whether in the case of positive sentinel lymph nodes, an axillary dissection can be done away with altogether without having any negative impact on the risk of loco-regional recurrence or on progression-free survival and overall survival. The results of the American ACOSOG-Z001 study have changed the fundamental perspective of this. In this study on the advantages of axillary dissection following the confirmation of tumour tissue in the sentinel lymph nodes, there were no statistically significant advantages from axillary dissection for women with a favourable overall risk profile who had received radiotherapy and systemic therapy. If this concept takes hold, the surgical treatment of node-positive breast cancer, at least in the axilla, would be reduced to a minimum, and the focus of treatment would in future lie more on the systemic treatment of this condition. As part of an interdisciplinary consensus meeting, a standardised approach for Austria with regard to this question was decided upon.

Background: Sentinel node (SN) biopsy after preoperative chemotherapy (PC) in breast cancer patients is associated with a lower identification rate (IR) and an increased false-negative rate (FNR) compared with SN biopsy in untreated patients. Our aims were to examine the feasibility of SN mapping before PC and the possibility to assess the lymph node status after chemotherapy through a follow-up lymphatic mapping., Methods: SN biopsy was performed in 45 clinically node-negative breast cancer patients before PC. A follow-up lymphatic mapping was done after completion of chemotherapy and irrespective of the lymph node status was followed by axillary lymph node dissection (ALND)., Results: SN mapping before chemotherapy identified a mean of 2.3 SNs in all patients (IR 100%). Nineteen patients revealed a negative SN; 26 patients had a positive SN (micrometastasis found in 6/26 patients). After PC follow-up lymphatic mapping was successful in 29 of 45 patients (IR 64%). IR for follow-up mapping was 80% for patients with a negative or micrometastatic SN before chemotherapy compared with 45% for patients with macrometastatic SNs (P = .027, Fisher exact test). None of the patients with a negative or micrometastatic SN before chemotherapy revealed positive lymph nodes after PC (P = .031, McNemar test) and the FNR for follow-up lymphatic mapping in these patients was 0%. Contrary to that, 15 of 20 patients with a macrometastasis before PC had positive nodes after chemotherapy, and the FNR of follow-up mapping in these patients was 50%., Conclusions: Patients with a negative SN before PC may forego complete ALND after PC, whereas this may not be valid for patients with macrometastatic SNs. Follow-up lymphatic mapping in patients with positive nodal status before chemotherapy is associated with a low IR and a high FNR.

Aims: To evaluate the feasibility of lymphatic mapping in breast cancer patients after previous axillary surgery and to identify parameters associated with mapping failure., Methods: Lymphatic mapping using peritumoural injection of blue dye and a radiocolloid was attempted in 30 patients with primary (n=7) or recurrent (n=23) breast cancer and a history of previous axillary lymph node dissection or sentinel node biopsy., Results: Lymphatic mapping identified a mean number of 1.6 (range 1-3) lymph nodes in 19 of 30 patients (identification rate 63%). The lymph nodes were removed from the ipsilateral axilla (n=13), the internal mammary chain (n=2), both the internal mammary nodes and the axilla (n=2), the interpectoral space (n=1) and the contralateral axilla (n=1). Four of 19 patients revealed a positive lymph node. Fifteen of 19 patients had a negative lymph node. Axillary lymph node dissection was done in 13 of 15 patients but found no positive nodes (false negative rate=0). A negative lymphoscintigram (p<0.001) and a number of more than 10 lymph nodes removed at the time of initial surgery (p=0.02) were significantly associated with a mapping failure., Conclusion: Lymphatic mapping following prior axillary surgery was accurate but associated with a low identification rate. The lymphatic drainage pattern was unpredictable and the use of a radionuclide was necessary for a successful mapping procedure.

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.

Introduction: In many countries sentinel node biopsy (SNB) has become the standard of care in breast cancer based on a large number of observational studies but without results from prospective randomized trials. The goal of our study was to evaluate the oncological safety of the SNB in breast cancer in a multicenter, nonrandomized setting with comparable groups., Patients and Methods: Between 1996/05 and 2004/11, 2942 patients from 14 departments in Austria with unicentric, unilateral, invasive disease without neoadjuvant therapy were collected in a database. The recommendations of the Austrian Sentinel Node Study Group were to complete a training period (phase I) with 50 cases of SNB followed by axillary lymph node dissection (ALND) to prove a detection rate of > or = 90% and a false-negative rate of < or = 5%. In the executing period (phase II), SNB was followed by ALND only if the sentinel node (SN) contained metastases. We compared the results on disease-free survival, local recurrence rates, distant recurrence rates and overall survival of both groups. Cases from phases I and II generated groups I (n=671) and 2 (n=2271 cases), respectively., Results: Overall mean follow-up time: 34.41 months., Conclusion: SNB followed by ALND only in cases with metastases in the SN is a safe procedure and at least equal to ALND in all cases.

Background: Operative techniques for oncoplastic reconstruction combine oncologic extirpation of the tumor with immediate reconstruction of breast shape and symmetry. These techniques are increasingly being used for breast-conservation therapy of centrally located breast carcinomas. The goal of this study was to provide an overview of the various surgical options for oncoplastic treatment of central breast carcinomas., Methods: From September of 1998 through January of 2005, 31 women (median age, 61 years) were treated for 32 centrally located breast carcinomas by breast-conserving therapy. There were 27 invasive tumors (median size, 13.5 mm), and five patients had ductal carcinoma in situ (median size, 39.6 mm). One patient received chemotherapy preoperatively for tumor reduction. A total of 11 patients had a positive lymph-node status, and 21 patients had a free sentinel node., Results: The various surgical techniques included a central lumpectomy with direct closure (n = 6), central lumpectomy with inverted T-closure (n = 2), a circumareolar, Benelli-type closure (n = 2), a modified Grisotti-flap closure (n = 9), and a mammaplasty-type closure with an inferiorly based pedicle (n = 13). In 27 patients, a contralateral procedure was undertaken (bilateral carcinoma or symmetrizing mammaplasty). Two patients required a secondary mastectomy because of ductal carcinoma in situ with positive surgical margins in the final histology. They were treated by immediate reconstruction with an implant and a pedicled myocutaneous latissimus dorsi flap, respectively. In a median follow-up of 33.8 months, there were no local recurrences in the remaining breast or axilla, but two patients developed distant metastases., Conclusions: Breast carcinoma of small size that occurs in a central location can be safely treated oncologically by breast conservation therapy. The use of various oncoplastic techniques yields very satisfactory aesthetic results.

Purpose: Multicentric breast cancer has been considered to be a contraindication for sentinel node (SN) biopsy (SNB). In this prospective multi-institutional trial, SNB-feasibility and accuracy was evaluated in 142 patients with multicentric cancer from the Austrian Sentinel Node Study Group (ASNSG) and compared with data from 3,216 patients with unicentric cancer., Patients and Methods: Between 1996 and 2004, 3,730 patients underwent SNB at 15 ASNSG-affiliated hospitals. Patient data were entered in a multicenter database. One hundred forty-two patients presented with multicentric invasive breast cancer and underwent SNB., Results: Intraoperatively, a mean number of 1.67 SNs were excised (identification-rate, 91.5%). The incidence of SN metastases was 60.8% (79 of 130). This was confirmed by axillary lymph node dissection (ALND) in 125 patients. Of patients with positive SNs, 60.8% (48 of 79) showed involvement of nonsentinel nodes (NSNs), as did three patients with negative SNs (false-negative rate, 4.0). Sensitivity, negative predictive value, and overall accuracy were 96.0%, 93.3%, and 97.3%, respectively. Ninety-one percent of the patients underwent mastectomy, and 9% were treated with breast conserving surgery. None of the patients have shown axillary recurrence so far (mean follow-up, 28.8 months). Compared with 3,216 patients with unicentric cancer, there was a significantly higher rate of SN metastases as well as in NSNs, whereas there was no difference in detection and false-negative rates., Conclusion: Multicentric breast cancer is a new indication for SNB without routine ALND in controlled trials. Given adequate quality control and an interdisciplinary teamwork of surgical, nuclear medicine, and pathology units, SNB is both feasible and accurate in this disease entity.

Background and Objectives: Occult invasive cancer found in reduction mammaplasty specimen in the contralateral breast in breast cancer patients requires axillary lymph node dissection (ALND) to assess the lymph node status. Routine Sentinel node (SN) biopsy in these patients may avoid secondary ALND when an occult cancer is found and the SN is negative in the permanent histological examination., Methods: One hundred sixty-nine breast cancer patients underwent contralateral reduction mammaplasty for symmetrization and with SN biopsy of the non-cancer breast. SN mapping was done using a vital blue dye alone (n = 136) or in combination with a radiocolloid (n = 33)., Results: A mean number of 1.4 SNs (range 1-3 SNs) was identified in 158 of 169 patients (identification rate 93.5%). One of 158 patients revealed a positive SN but no tumor was found in the reduction mammaplasty/mastectomy specimen, whereas the SN was negative in 157 patients. Histological examination of the 169 reduction mammaplasty specimen revealed 5 occult invasive cancers and 4 patients with high grade DCIS but due to a negative SN biopsy the patients were spared a secondary ALND., Conclusion: The small number of patients with occult contralateral cancers may not warrant routine SN mapping in patients scheduled for contralateral reduction mammaplasty., (Copyright 2006 Wiley-Liss, Inc.)

Background: Intraoperative frozen section examination of the sentinel node in breast cancer patients is associated with a high number of incorrect negative results with the sentinel node becoming positive in the permanent examination and necessitating a secondary axillary lymph node dissection. A reoperation of the axilla following skin-sparing mastectomy and immediate autologous tissue reconstruction may compromise the vascular pedicle of the flap and should be avoided., Methods: Eighty breast cancer patients underwent skin-sparing mastectomy with immediate autologous reconstruction and sentinel node biopsy followed by axillary lymph node dissection irrespective of the result of the frozen section of the sentinel node. The goal of the study was to identify a subgroup of patients with incorrect negative sentinel node(s) in the frozen section who may forego a secondary axillary lymph node dissection due to a low risk of positive nonsentinel nodes., Results: Frozen section examination of the sentinel node was negative in 58 patients and positive in 22 patients. Permanent histologic examination revealed tumor in 13 of 58 (22.4 percent) sentinel node(s) found negative in the frozen section. None of these 13 patients showed positive nodes in the axillary specimen, whereas nine of 22 patients with their metastases in the sentinel node found through intraoperative frozen section examination had additional positive nonsentinel node(s) (p = 0.001)., Conclusions: Patients with incorrect negative sentinel node(s) found in the frozen section examination had a significantly decreased risk for additional positive nonsentinel node(s) compared with patients with sentinel node metastases found in the frozen section. However, to avoid a secondary axillary lymph node dissection, the authors suggest performing sentinel node biopsy before mastectomy under local anesthesia to have the permanent result of the sentinel node available before a planned reconstruction.

Background: Axillary lymph node dissection (ALND) may not be necessary in women with breast cancer who have micrometastasis in a sentinel node (SN), owing to the low risk of non-SN (NSN) involvement. The aim of this study was to identify a subgroup of women with a micrometastatic SN and a negligible risk of positive NSNs in whom ALND may be avoided., Methods: Some 237 of 241 women with a macrometastatic SN and 122 of 138 with a micrometastatic SN underwent completion ALND and were compared with respect to NSN involvement. The 122 patients with SN micrometastasis were further analysed to determine factors that could predict the risk of positive NSNs., Results: A total of 121 (51.1 per cent) of 237 women with SN macrometastasis had positive NSNs compared with 22 (18.0 per cent) of 122 with SN micrometastasis (P < 0.001). Multivariate analysis showed that size of SN micrometastasis (odds ratio 3.49 (95 per cent confidence interval (c.i.) 1.32 to 9.23); P = 0.012) and presence of lymphovascular invasion (odds ratio 0.23 (95 per cent c.i. 0.05 to 1.00); P = 0.050) were significantly associated with positive NSNs. SN micrometastasis less than 0.5 mm in diameter combined with absence of lymphovascular invasion was associated with an 8.5 per cent risk of NSN involvement., Conclusion: Size of micrometastasis and presence of lymphovascular invasion were significantly related to the risk of finding additional positive axillary lymph nodes when the SN contained only micrometastasis., (Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Aim of the Study: Intraoperative frozen section (FS) examination of the Sentinel node (SN) in breast cancer patients is questioned due to the relatively high number of positive SN(s) found in the permanent histological examination. This study reviews the data of the Austrian sentinel node study group on FS examination of the SN and tries to identify patients with a high risk of incorrect negative results., Methods: 2326 breast cancer patients of the Austrian Sentinel node study group who underwent SN biopsy and intraoperative FS examination of the SN were further analysed for incorrect negative results and clinicopathologic factors indicating a higher rate of incorrect negative results., Results: The FS of the SN was positive in 513 of 2326 patients (22.1%) and negative in 1813 of 2326 patients (77.9%). Permanent histological examination revealed a metastatic SN in 282 of 1813 patients. (incorrect negative rate 15.6%). 158 of 282 patients (56%) were found through H&E serial sectioning, whereas 124 of 282 patients (44%) were only seen in immunohistochemistry. Micrometastases, lobular histology and preoperative chemotherapy were associated with a higher rate of incorrect negative results., Conclusion: Incorrect negative results of FS examination are seen in 15% of patients and require a secondary axillary lymph node dissection. The disadvantage of missing a positive SN through FS is by far outweighed by the advantage of a single stage operation in case of a positive SN.

Preoperative breast biopsy might cause disaggregation of tumour cells and tumour cell spread. The purpose of this study was to investigate the impact of preoperative biopsy on the rate of metastases to the sentinel lymph node (SLN) of patients with primary breast cancer. We report the results of 2502 patients with primary breast cancer, who were operated, and a sentinel node biopsy was performed. The association of preoperative biopsy with the risk of SLN metastases was examined by regression analyses and tested for possible confounding well-known factors for axillary node metastases. In all, 1890 patients were available for final analyses; 1048 (55.4%) patients had a preoperative diagnosis performed by fine-needle aspiration or core biopsy; 641 (33.9%) patients had a positive SLN when conventional H&E and IHC staining was performed. Patients with preoperative breast biopsy showed a 1.37 times (95% CI, 1.13-1.66) increased risk of SLN metastases on univariate analysis, but this result was not persistent when analysis was adjusted for other relevant factors for axillary node metastases, OR 1.09 (95% CI, 0.85-1.40). In addition, subgroup analyses of the risk for occult micro metastases to the SLN (detected by IHC only) on H&E-negative cases also showed no increased risk associated with preoperative biopsy, OR 1.07 (95% CI, 0.69-1.65). The conclusion, based on the present data, is that preoperative breast biopsy does not cause artificial tumour cell spread to the SLN, with possible negative impact on the prognosis of breast cancer.

Background/aims: The excellent results of new devices like the new bipolar feedback-controlled sealing system (LigaSure) for closure of blood vessels encouraged surgeons to use these instruments for other structures like bile ducts. The aim of this study was to evaluate the feasibility of closure of cystic duct in case of biliary obstruction., Methodology: Ten domestic pigs underwent laparoscopic cholecystectomy sealing the cystic duct with LigaSure. The common bile duct was closed with an endoclip to create a biliary hypertension. On the 12th postoperative day blood samples were taken for liver enzymes. At autopsy on day 15 the pigs were investigated for bile leaks or biliary peritonitis. The cystic duct was resected for histological examination., Results: Seven pigs survived, one pig died during introduction of anesthesia, one on the 1st and one on the 2nd postoperative day without any findings at the autopsy. One pig out of 7 had a bile leak; the other 6 were without any sign of leakage. Histologically 3 pigs had a regular coagulation zone at the cystic duct, 3 had a total necrosis, one a partial necrosis of the mucosa only., Conclusions: Though there was only one insufficiency, the feedback-controlled bipolar vessel sealer cannot be recommended for biliary surgery with regard to the high rate of necrosis stated in our experiment.

Sentinel node (SN) biopsy in breast cancer patients following preoperative chemotherapy is associated with a decreased identification rate and an increased false-negative rate when compared to SN biopsy performed in untreated patients. We performed SN biopsy in 21 breast cancer patients scheduled for preoperative chemotherapy using either vital blue dye alone (n = 11) or in combination with a radiocolloid (n = 10). Following a mean of four cycles of preoperative chemotherapy, surgery to the breast and complete axillary lymph node dissection was performed irrespective of the SN status. A mean of 1.9 SNs were identified in all 21 patients, 12 were SN negative and 9 were SN positive. Preoperative chemotherapy decreased mean tumor size from 40.2 to 17.7 mm and breast conservation was possible in 14 of 21 patients (67%). All SN-negative patients and three of nine SN-positive patients had negative lymph nodes in the axillary specimen, whereas six of nine patients with a positive SN revealed lymph node metastases following preoperative chemotherapy. SN biopsy performed before preoperative chemotherapy found a 100% identification rate with no false-negative results. Following preoperative chemotherapy, SN-negative patients may forego a complete axillary dissection.

Background: Transilluminated powered phlebectomy is a new procedure for minimal invasive varicose vein surgery., Objective: To evaluate this technique for its benefit and the technique-related risks and complications., Methods: Thirty patients were prospectively operated with this new technique by the same surgeon (11 of them bilaterally [41 legs in all]). According to the sonography, sapheno-femoral-junction ligation and stripping of the long saphenous vein were done if necessary. The phlebectomy of the side branches was done with the new system (Trivex System/Smith and Nephew). The postoperative follow-up was at 10 days and 6 weeks., Results: There was no intraoperative complication. The mean operation time per leg was 40 minutes. Twenty-five patients had an uneventful postoperative course. Twenty two have been very satisfied with the cosmetically result. Two patients required reoperation because of postoperative hematoma. One patient developed a seroma, which could be managed via puncture. One patient developed persistent brown scar. The overall morbidity was 12.2%., Conclusion: Using transilluminated powered phlebectomy, multiple and large incisions could be reduced. A perfect cosmetic outcome might be reached if the surgeon is aware of technique-related complications. To evaluate the real value of this technique, further randomized trials are necessary.

Background: This study compared bilateral and unilateral varicose vein surgery in primary varicosis of the long or short saphenous vein with respect to blood loss., Patients and Methods: The prospective trial assessed postoperative pain, analgesic consumption, blood loss, return to physical activity and work, cosmetic result, complications, hospitalization, patient satisfaction, and hospital cost in 73 consecutive patients undergoing unilateral ( n=40) or bilateral ( n=33) varicose vein surgery., Results: There were no statistically significant differences between the two groups in postoperative pain, postoperative analgesic consumption immediately postoperatively and after 8 h, median postoperative stay, return to work and physical activity, or cosmetic result. All patients but one were either satisfied or very satisfied 6 weeks postoperatively., Conclusions: Patients undergoing a bilateral stripping operation did not differ from those undergoing unilateral operation. Therefore we recommend bilateral operation when indicated.

Background and Objectives: The number of sentinel lymph nodes (SLNs) removed during biopsy may have an impact on the accuracy of finding a positive SLN. This study investigated various factors to determine if they had any significant correlation with the number of SLNs found during biopsy. In patients with positive SLNs, the nodes were then analyzed to determine which SLN contained metastasis., Methods: For 263 patients with breast cancer who successfully underwent SLN biopsy, parameters such as tumor size, histologic characteristics, differentiation, and receptor status, patient age, breast quadrant, type of surgery, mapping with blue dye only or with radiocolloid, and whether biopsy was performed before or after tumorectomy were prospectively collected. These factors were analyzed to determine whether they had any significant correlation to the number of removed lymph nodes. Positive SLNs were ranked in the order they were removed and examined for which node contained the metastasis., Results: During biopsy, a mean of 1.8 (range, 1-5) SLNs were found. The SLNs were negative in 158 patients and positive in 105. The number of SLNs removed was comparable between node-negative and node-positive patients, and none of the parameters analyzed was significantly related to the number of SLNs removed. Of the 105 patients with a positive SLN, the first SLN independently predicted the pathologic status of the axilla in 96 patients (91.4%; 95% CI 86.1-96.8), and the first and second SLN independently predicted the status in 104 patients (99%; 95% CI 97.2-100). Only one of 105 patients had metastasis in the third SLN removed., Conclusion: The pathologic status of the axilla was independently determined by removal of the first or first and second SLN in 99% of patients; removal of more than three SLNs did not increase the accuracy of finding a positive node., (Copyright 2002 Wiley-Liss, Inc.)

Background: Bile leaks are serious complications after laparoscopic cholecystectomy. The aim of this study was to evaluate the feasibility of closure of the cystic duct with a new feedback-controlled bipolar sealing system (LigaSure)., Methods: Ten domestic pigs underwent open cholecystectomy with the cystic duct and artery dissected and sealed with the new bipolar sealing system (LigaSure). Four and 8 days postoperatively, 5 pigs each were sacrificed and the closure of the cystic duct was evaluated. The cystic stump and the common bile duct were excised for histological examination., Results: None of the pigs had a bile leak or a biliary peritonitis. There were no signs of postoperative bleeding or inflammation in Calot's triangle. Histology showed total necrosis of the cystic duct in the first two pigs due to too much energy used. The remaining specimens showed a regularly scaling zone without necrosis in 7 cases, and in one case a partial necrosis in the mucosa only was found., Conclusion: Cystic artery and cystic duct closure with the new device may be an alternative to the clip. Further trials should evaluate the feasibility and safety of the new device in the clinical setting.

Background: The patient's view of the outcome after phlebectomy is mainly dependent on the cosmetic result., Objective: To compare 5-0 monofilament sutures with tapes and tissue adhesive for wound closure after varicose vein surgery., Methods: Seventy-nine patients undergoing varicose vein surgery were prospectively randomized in three groups (tissue adhesive, sutures, tape) for skin closure and compared. The follow-up 1 year postoperatively was done by a senior dermatologist who was blinded in the method of skin closure., Results: The cosmetic outcome showed little advantage for the suture group. Taping the incisions is faster than suturing them but without significance; closure with tissue adhesive takes nearly the double of time. The closure for one incision with tissue adhesive is 40 times more expensive than with tapes and 14 times more expensive than with sutures., Conclusion: This study failed to demonstrate an advantage of tissue adhesive and tapes over monofilament sutures for skin closure after phlebectomy.

Background and Objectives: The purpose of this study was to evaluate the feasibility of sentinel lymph node biopsy in breast cancer patients at our institution and to report the follow-up status of node-negative patients with removal of only the sentinel node., Methods: A total of 247 breast cancer patients underwent sentinel node (SN) mapping between June of 1996 and September of 2000. The SN was identified by using a combination of vital blue dye and a radiolabeled colloid., Results: A SN was identified in 227 of 247 patients (91.9%). One hundred forty-five were SN negative, 82 were SN positive. All SN-positive patients underwent axillary dissection of level I and II, whereas 83 patients with a negative SN had SN biopsy only. Median follow-up of these patients at 22 months revealed no axillary recurrence; the morbidity resulting from SN biopsy was negligible., Conclusions: Although the follow-up is very short, SN biopsy only in node-negative breast cancer patients had no negative impact on the axillary failure rate and resulted in negligible morbidity., (Copyright 2001 Wiley-Liss, Inc.)

Aims: The purpose of this study was to evaluate the feasibility of sentinel lymph-node biopsy in breast cancer patients at our institution and to compare the results of sentinel node (SN) biopsy to standard axillary lymph-node dissection (ALND)., Methods: In a retrospective study the percentage of lymph-node positive patients and the number of micrometastases in 165 breast cancer patients following SN biopsy was compared to 195 patients who underwent ALND of level I and II without SN biopsy. The SN was identified using a combination of vital blue dye and a radiolabelled colloid., Results: Patients and tumour characteristics were comparable between both groups. SN biopsy found no significant difference in the number of node positive T1 cancer patients (SN group: 31/108 (28.7%) -- ALND group: 21/92 (22.8%)) and T2 tumours (SN group: 27/57 (47.4%) -- ALND group: 49/103 (47.6%)) between both groups. Micrometastases were more frequently found in the SN group when compared to the ALND group (six of 70 positive nodes) (P=0.04)., Conclusion: SN biopsy may be as accurate as standard axillary lymph-node dissection for the evaluation of the axillary lymph-node status in breast cancer patients., (Copyright Harcourt Publishers Limited.)

Introduction: The purpose of this prospective controlled study was to evaluate the diagnostic potential of spiral computed tomographic (CT) cholangiography in patients undergoing laparoscopic cholecystectomy., Methods: 60 patients (17 men, 43 women, mean age 54.5 years, range 15-84 years) with symptomatic cholecystolithiasis were included in this study. After infusion of meglumine jodoxamate, all patients underwent upper abdominal spiral CT. The results of the spiral CT scan were then compared with endoscopic retrograde cholangiography (ERC) or intraoperative cholangiography., Results: In 53 patients (88%) CT cholangiography was considered to be technically adequate for interpretation, but was suboptimal in 4 patients (7%) and nondiagnostic in 3 patients (5%), respectively. CT cholangiography showed a stone free common bile duct in 51 patients which was correct in all cases. CT cholangiography predicted a common bile duct stone in 6 patients which proved to be correct in 4 patients but was found to be incorrect in 2 patients., Conclusion: Spiral CT cholangiography is useful for the diagnosis of common bile duct stones. Because of the low positive predicting value routine use before laparoscopic cholecystectomy is not justified.

Background: Axillary lymph node dissection for staging the axilla in breast carcinoma patients is associated with considerable morbidity, such as edema of the arm, pain, sensory disturbances, impairment of arm mobility, and shoulder stiffness. Sentinel lymph node biopsy electively removes the first lymph node, which gets the drainage from the tumor and should therefore be associated with nearly zero morbidity., Methods: Postoperative morbidity (increase in arm circumference, subjective lymphedema, pain, numbness, effect on arm strength and mobility, and stiffness) of the operated arm was prospectively compared in 35 breast carcinoma patients after axillary lymph node dissection (ALND) of Level I and II and 35 patients following sentinel lymph node (SN) biopsy., Results: Patient characteristics were comparable between the two groups. Postoperative follow-up was 15.4 months (range, 4-28 months) in the SN group and 17.0 months (range, 4-28 months) in the ALND group. Following axillary dissection, patients showed a significant increase in upper and forearm circumference of the operated arm compared with the SN patients, as well as a significantly higher rate of subjective lymphedema, pain, numbness, and motion restriction. No difference between the two groups was found regarding arm stiffness or arm strength, nor did the type of surgery affect daily living., Conclusions: SN biopsy is associated with negligible morbidity compared with complete axillary lymph node dissection., (Copyright 2000 American Cancer Society.)

Breast conserving surgery is the therapy of choice in breast cancer patients and may avoid mastectomy in most of the patients. New treatment options such as sentinel lymph node biopsy may avoid complete axillary dissection in selective patients. Plastic reconstructive procedures like immediate reconstruction or oncoplastic surgery decrease physical sequelae and increase the quality of life and should be offered to all breast cancer patients: Modern breast cancer management requires intense cooperation of all cancer subdisciplines.

Mesenteric cysts are rare benign intraabdominal lesions without typical clinical findings. Treatment is indicated if they become symptomatic due to enlargement of the cyst. We report 3 patients who were treated by laparoscopic surgery. In 3 patients (3 women, ages 18, 18, 46 years) admitted to our hospital with uncharacteristic abdominal pain, a mesenteric cyst 4.5-18 cm in diameter was diagnosed by ultrasonography and CT scan or MRI. One cyst was partially resected laparoscopically by unroofing of the surface, and the other two were resected completely. There were no intra- or postoperative complications. During follow-up, cyst recurrence was diagnosed in the patient with cyst unroofing 10 months after surgery, and complete cyst resection was successfully performed laparoscopically. Mesenteric cysts can be successfully managed laparoscopically. In order to prevent recurrence, complete resection should be performed.

Background: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix., Methods: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix., Results: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance., Conclusions: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen.

Sentinel lymph node (SN) biopsy in primary breast cancer seems to be an alternative to complete axillary lymph node dissection for evaluation of the axillary lymph node status in selected patients. Following evaluation of the technique of SN biopsy, we applied SN biopsy clinically to 23 selected patients. A lymphoscintigraphy was performed preoperatively to evaluate lymphatic drainage. The SN was identified in the operating room by use of a hand-held gamma camera and a blue vital dye. The SN was found in all 23 patients. In 17/23 the SN was tumor free and no axillary dissection was performed; 6/23 showed a positive SN and complete axillary dissection was done. Intraoperative lymphatic mapping and SN biopsy may be the treatment of choice for evaluation of axillary node status in selected patients, for it combines accurate nodal staging and low morbidity.

Objective: To evaluate the short and long term results of video-assisted thoracoscopic surgery for complicated pneumothorax., Design: Retrospective study., Setting: General hospital, Linz, Austria., Subjects: 76 consecutive patients with complicated pneumothorax., Interventions: 57 patients with primary and 19 with secondary spontaneous pneumothorax underwent video-assisted thoracoscopic surgery. Depending on the findings at thoracoscopy, patients were allocated to have stapled bleb resection (n=29), multiple bleb resection combined with apical pleurectomy (n=40), or apical segmental resection combined with apical pleurectomy (no visible disease on the lung surface, n=7)., Main Outcome Measures: Efficacy, morbidity, mortality, and late recurrence rate., Results: No conversions to open thoracotomy were necessary and early lung reexpansion was achieved in all but one patient (99%). There was one postoperative death (1%) and morbidity was 7%, including one persistent air leak and one early recurrence, both of which required thoracotomy. All postoperative complications developed in patients with spontaneous pneumothorax secondary to diffuse bullous emphysema. At a median follow up of 34 months there were 4 ipsilateral pneumothorax recurrences (5%), two of which developed after bleb resection combined with pleurectomy and two after bleb resection alone., Conclusion: Video-assisted thoracoscopic surgery was safe and effective for the treatment of complicated spontaneous pneumothorax. It is our procedure of choice for complicated primary spontaneous pneumothorax and is a valuable alternative to open thoracotomy for patients with secondary spontaneous pneumothorax.

Background: Modified logistic regression analysis of 24 variables in 300 patients undergoing laparoscopic cholecystectomy found the following parameters independently predictive for a difficult operation: right upper quadrant pain (p < 0.01), rigidity in right upper abdomen (p < 0.01), previous upper abdominal surgery (p < 0.01), biliary colic within the last 3 weeks (p < 0.05), white blood cell count > 10 x 10(9)/l (p < 0.05), thickening of the gallbladder wall (p < 0.05), hydroptic gallbladder (p < 0.05), pericholecystic fluid (p < 0.01), shrunken gallbladder (p < 0.01), and no filling of the gallbladder in preoperative intravenous cholangiography (p < 0.05)., Methods: Based on these variables a diagnostic model was developed to predict the difficulty of a laparoscopic cholecystectomy, with scores ranging from 0 (ideal case) to IV (conversion to open cholecystectomy expected) prior to surgery., Results: When the reliability of our model was examined in a second study in 340 consecutive patients undergoing laparoscopic cholecystectomy 80% of the patients were predicted correctly., Conclusions: Our model should help to select patients for either laparoscopic or open cholecystectomy based on the expected difficulties and the experience of the surgeon.

In a prospective randomized study postoperative pain, analgesic consumption, return to physical activity and work, cosmetic result and experience with the type of operation were assessed in 86 patients undergoing inguinal hernia repair by means of either the Shouldice technique (n = 34), the laparoscopic transabdominal preperitoneal (TAPP) (n = 28) or total preperitoneal (TPP) (n = 24) repair. Patients having TAPP repair had decreased visual analogue scale scores for pain on the day of operation compared with those undergoing TPP and Shouldice repair (4.8 versus 6.5 and 6.2 respectively, P = 0.02) and on the first postoperative day compared with TPP (4.0 versus 6.0, P = 0.01). There was no difference between the three groups for days 2, 3, 4, 5 and 30 after operation. Patient satisfaction with the operation, analgesic consumption, return to physical activity such as walking, driving, climbing stairs, running, bicycling and sexual intercourse, as well as return to work, was comparable in the three groups. There was a better cosmetic result after TAPP and TPP repair. This study failed to demonstrate significant benefits from laparoscopic hernia repair over the Shouldice technique.

Background: The indications for video-assisted thoracoscopy have steadily expanded during recent years and include now the management of various mediastinal disorders., Methods: Until now we have used videothoracoscopy for the diagnosis or treatment of mediastinal mass lesions in 28 patients. The indication for the procedure was bilateral or unilateral mediastinal adenopathy in 16, a suspected malignant anterior mediastinal mass lesion in six, and a presumable benign tumor of the posterior or anterior mediastinum in six patients., Results: Video-assisted thoracoscopy provided an accurate tissue diagnosis in all patients with adenopathy and in all but one patient with a malignant mass lesion of the anterior mediastinum. It further allowed complete excision of all benign tumors of the anterior or posterior mediastinum. There were no intra- or postoperative complications, but conversion to open thoracotomy was necessary in one patient., Conclusions: Video-assisted thoracoscopy is a valuable adjunct to traditional surgical techniques for the diagnosis of malignant mediastinal disease and may overcome some of the limitations of mediastinoscopy and mediastinotomy. In the future, it may become the procedure of choice for the resection of small benign tumors of the anterior or posterior mediastinum.

Background: Inadvertent injury to the bowel is a rare but potentially fatal complication of laparoscopy. Such injury often goes unrecognized at the time of the procedure and only later is manifest by high morbidity and mortality., Methods: We reviewed the mechanism and management of 10 instances of bowel injury known to have been encountered in a series of 4672 laparoscopic procedures performed at our hospital over the past 5 years., Results: The usual causes of injury to the bowel wall were thermal burns, sharp dissection, and needle punctures. Six of the injuries were readily evident and treated immediately; four were unrecognized until 2 to 14 days after the procedure. One patient died of multiple organ failure on the third day after laparoscopy. Operative management in nine cases required simple closure or segmental resection. A high index of suspicion and vigilant physical examination were the keys to early recognition of bowel injury; laboratory and radiographic findings were nonspecific., Conclusions: Suspected bowel injury following laparoscopy mandates early laparotomy to avoid life-threatening complications.

Background: The purpose of a prospective randomized study was to compare the surgical trauma in patients undergoing laparoscopic or open hernia repair., Methods: Postoperative pain, analgesic consumption, and metabolic response to surgery were assessed in 30 patients undergoing laparoscopic (group 1; n = 15) or open (group II; n = 15; Shouldice repair) unilateral inguinal hernia repair. Both groups were comparable with respect to age, sex, and type and size of inguinal hernia., Results: Postoperative visual analogue scales (VAS) for pain were reduced on mobilization for patients of group I with a significant difference (P = 0.02) on the operative day, whereas pain scores at rest and analgesic requirements were similar for both groups. No differences between groups I and II were found in postoperative levels of interleukin-1, interleukin-6, tumor necrosis factor alpha, C-reactive protein, fibrinogen, transferrin, alpha-1-antitrypsin, and white blood cells. Postoperative polymorphonuclear (PMN) elastase concentrations remained within normal range in group II but showed a significant increase in patients operated laparoscopically for postoperative days 1 and 2., Conclusions: No major surgical trauma was found after herniorraphy compared to open hernia repair.

Diagnostic laparoscopy was performed in 72 patients for diagnosis of suspected cancer or staging of intraabdominal malignancies. In 66 of 72 patients (91.7%) a diagnosis was possible laparoscopically and in 53 patients (73.6%) a laparotomy was avoided. In 19 of 72 patients (26.4%) laparoscopy changed staging of preoperative non-invasive test and helped to plan proper surgical management. Laparoscopy has proved to be an effective diagnostic tool in abdominal malignancies and should help to avoid unnecessary laparotomies in case of incurable disease. It should be used complementary to non-invasive imaging methods and the addition of laparoscopic ultrasonography will improve the accuracy of examination.

In 1,300 patients undergoing laparoscopic cholecystectomy (LC) 56 patients (4.3%) required conversion to open cholecystectomy (OC); 41 (73%) of the conversions were elective, whereas 15 (27%) were enforced. The causes of the 56 conversions are described and analyzed. Logistic regression analysis of 23 parameters identified the following data as associated with a higher risk for conversion: pain or rigidity in the right upper abdomen (P < 0.01), thickening of the gallbladder wall on preoperative ultrasound (P < 0.05), intraoperatively found dense adhesions to the gallbladder or in Calot's triangle (P < 0.001), and intraoperatively found acute inflammation of the gallbladder (P < 0.01). Clinical findings of an acute cholecystitis associated with intraoperative dense scarring in Calot's triangle were the best factors predicting conversion from LC to OC. As a result of the study we preoperatively select our patients for either LC or OC, and a difficult case is performed by a more experienced surgeon to keep conversion rate and complications low.

With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.

From January 1991 to June 1993 the authors performed 92 diagnostic laparoscopies when physical examination, laboratory tests, and noninvasive imaging techniques failed to provide accurate diagnoses. Thirty-three patients (36%) underwent laparoscopy to ensure or exclude diagnosis in suspected intra-abdominal malignancy or to assess the operability in the cases of known cancer; 31 patients (34%) were evaluated for chronic abdominal pain; 15 patients (16%) were evaluated for acute abdominal pain; 9 trauma patients (10%) were evaluated to exclude or confirm penetration of the peritoneum or laceration of intra-abdominal organs; and 4 patients (4%) were operated on for miscellaneous conditions. Of the 92 patients, laparoscopy led to diagnosis in 80 patients (87%), a laparotomy was avoided in 78 patients (85%), and operative treatment was done laparoscopically in 65 patients (71%). Diagnostic laparoscopy will not replace laparotomy in every instance. However, in selected groups of patients, it may be used to yield diagnosis and help to avoid unnecessary laparotomy.