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Study Objective: To compare functional outcomes, recurrence rate, and pregnancy likelihood in patients undergoing conservative or radical surgery for deep rectal endometriosis followed up for 7 years. Design: Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013. Setting: A tertiary referral center. Patients: Fifty-five patients with deep endometriosis infiltrating the rectum. Interventions: Patients underwent either segmental resection or nodule excision via shaving or disk excision, depending on randomization that was performed preoperatively using sequentially numbered, opaque sealed envelopes. Measurements and Main Results: The primary end point was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence, or bladder dysfunction 24 months after surgery. The secondary end points were values of gastrointestinal and overall quality of life scores. The 7-year recurrence rates (new deep endometriosis nodules infiltrating the rectum) in the excision vs segmental resection arms were 7.4 % vs 0% (p =.24). One of the symptoms included in the definition of the primary outcomes was recorded in 55.6% vs 60.7% of patients (p =.79). However, 51.9% vs 53.6% of patients considered their bowel movements as normal (p =.99). An intention-to-treat comparison of overall quality of life scores did not find a difference between the 2 groups 7 years after surgery. At the end of the 7-year study period, 31 of 37 patients who tried to conceive were successful (83.8%), including 27 pregnancies (57.4%) resulting from natural conception and 20 pregnancies (42.6%) resulting from assisted reproductive technology procedures. The pregnancy rate was 82.4% vs 85% in the 2 arms (p =.99). A 75.7% live birth rate was recorded. At the end of the follow-up, there were 15 women with 1 child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow-up, the reoperation rates were 37% and 35.7%, respectively, in each arm (p =.84). Among the 27 reoperation procedures during the follow-up period, 11 (40.7%) were for postoperative complications, 7 (25.9%) were necessary before assisted reproductive technology management, 8 (29.6%) were for recurrent abdominal or pelvic pain, and 1 (3.7%) was for midline ventral hernia after pregnancy. Conclusion: Our study did not reveal a considerable difference in terms of digestive functional outcomes, recurrence rate, reoperation risk, and pregnancy likelihood when conservative and radical rectal surgeries for deep endometriosis were compared 7 years after surgery. The postoperative pregnancy rate observed in our series was high.

International audience; Background: The French Society of Surgery has endorsed a cohort aiming to prospectively assess the frequency of recurrence after incisional hernia repair and to identify the risk factors.Methods: Consecutive patients undergoing incisional hernia repair in the participating centers were included in the prospective French Society of Surgery cohort over a 6-month period. Patients were followed up with a computed tomography scan at 1 y and a clinical assessment by the surgeon at 2 years.Results: A total of 1,075 patients undergoing incisional hernia repair were included in 61 participating centers. The median follow-up was 24.0 months (interquartile range: 14.0-25.3). The follow-up rates were 83.0% and 68.5% at 1 and 2 years, respectively. The recurrence rates were 18.1% at 1 year and 27.7% at 2 years. Recurrence risk factors at 2 years were a history of hernia (odds ratio = 1.57, 95% confidence interval = 1.05-2.35, P = .028), a lateral hernia (odds ratio = 1.84, 95% confidence interval = 1.19-2.86, P = .007), a concomitant digestive operation (odds ratio = 1.97, 95% confidence interval = 1.20-3.22, P = .007), and the occurrence of early surgical site complications (odds ratio = 1,90, 95% confidence interval = 1.06-3.38, P = .030). The use of surgical mesh was strongly associated with a lower risk of recurrence at 2 years (P < .001).Conclusion: After incisional hernia repair, the 2-year recurrence rate is as high as 27.7%. History of hernia, lateral hernia, concomitant digestive operation, the onset of surgical site complications, and the absence of mesh are strong risk factors for recurrence.

Barber’s abscess is an acquired occupational disease, thought to be caused by short hair clippings that enter the susceptible web space skin, usually seen in male barbers. This case report is to report a rare case of a female barber, who developed a pilonidal sinus (PS) in the interdigital web space of her non-dominant left hand, requiring excision with a flap reconstruction and also to review the relevant literature. A 46-year-old female barber underwent day case surgical excision of the PS with a Foucher flap reconstruction of her left non-dominant hand, third web space. The patient remains disease-free 3 years on. PS of the interdigital space of the hand is a rare and preventable acquired occupational disease. Personal hygiene and meticulous removal of any hair clippings from the web space could prevent the formation of the pilonidal sinus.

Aim: The aim of this work was to assess whether placement of a biological mesh (Permacol®) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis. Method: We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3 cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups. Results: Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3 cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4 ± 1.4 cm vs. 6 ± 2.9 cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3–9.5). A distance of less than 7 cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7–132). Conclusion: Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

Background Several pre‐analytical factors can affect the measurement of intact Parathyroid Hormone (IPTH). In this study, we have investigated the effects of using different types of tubes, time elapsed before separation, and storage conditions over time on the measured values of IPTH. Method Blood samples from 30 subjects were collected into plain, SST, and EDTA tubes. All serum and plasma were separated immediately (first set) and after 2 hrs delay (second set). The first set of samples were aliquoted and stored at RT (25°C), at fridge (4°C), and freezer (−20°C). IPTH was measured in all the stored aliquots at 2,4, and 8 days after collection using Architect analyzer. Results Paired T test and ANOVA repeated measures showed no significant difference between IPTH levels in all tubes. The second set of serum and plasma were significantly lower (3.8% and 7.4%, p, Intact Parathyroid Hormone (IPTH) can be affected by different pre‐analytical factors. In this study, we investigated the effect of different types of tubes, delay in sample separation, and different storage temperature on the measured IPTH values. We found that plasma IPTH can be stored at RT for up to four days. Both plasma and serum IPTH are not affected by a delay in separation of up to two h and they can be stored for up to 8 days in a fridge or freezer without any clinically significant changes in their values.

Summary:. The anterioabdominal wall is the most common site for low molecular weight heparin administration for anticoagulation, either for prophylactic or for therapeutic indications. Occasionally, this could be associated with damage of the abdominal pannus microvasculature, which could possibly jeopardize the reliability of free abdominal flaps as deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle, especially with therapeutic anticoagulation therapy. These flaps are reliant on a highly intricate complex vascular anatomy and perforasomes for their adequate perfusion and survival. The authors report a case of nonobstructive microvascular failure of a free muscle sparing transverse rectus abdominis muscle utilized for soft tissue coverage following resection of a chest wall breast cancer recurrence on a background of portacath-induced deep venous thrombosis of the axillary and subclavian vein whilst on chemotherapy. History of long-term therapeutic low molecular weight heparin administration in the abdomen resulted in microangiopathic densities evident on computerized tomography scan with subsequent flap failure due to possible jeopardization of the flap microvasculature and perfusion. Following exclusion of common local and systemic factors that can cause vascular compromise, a debridement and salvage re-reconstruction procedure utilizing a contralateral free latissimus dorsi flap was performed. Reconstructive surgeons should be cautious when planning to utilize free abdominal-based flaps on the background of long-term therapeutic low molecular weight heparin administration in the abdomen and may possibly explore other alternative options of using non-abdominal free flaps from the reconstructive armamentarium within this unique context.

STUDY QUESTION Is there a difference in functional outcomes and recurrence rate between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 5 years postoperatively? SUMMARY ANSWER No evidence was found that long-term outcomes differed when nodule excision was compared to rectal resection for deeply invasive endometriosis involving the bowel. WHAT IS KNOWN ALREADY Functional outcomes of nodule excision and rectal resection for deeply invasive endometriosis involving the bowel are comparable 2 years after surgery. Despite numerous previously reported case series enrolling patients managed for colorectal endometriosis, long-term data remain scarce in the literature. STUDY DESIGN, SIZE, DURATION From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Among them, 55 women were enrolled at one tertial referral centre in endometriosis, using a randomization list drawn up separately for this centre. Institute review board approval was obtained to continue follow-up to 10 years postoperatively. One patient requested to stop the follow-up 2 years after surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients underwent either nodule excision by shaving or disc excision, or segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of randomization results. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were values taken from the Knowles–Eccersley–Scott-symptom questionnaire (KESS), the gastrointestinal quality of life index (GIQLI), the Wexner scale, the urinary symptom profile (USP) and the Short Form 36 Health Survey (SF36). MAIN RESULTS AND THE ROLE OF CHANCE Fifty-five patients were enrolled. Among the 27 patients in the excision arm, two were converted to segmental resection (7.4%). One patient managed by segmental resection withdrew from the study 2 years postoperatively, presuming that associated pain of other aetiologies may have jeopardized the outcomes. The 5 year-recurrence rate for excision and resection was 3.7% versus 0% (P = 1), respectively. For excision and resection, the primary endpoint was present in 44.4% versus 60.7% of patients (P = 0.29), respectively, while 55.6% versus 53.6% of patients subjectively reported normal bowel movements (P = 1). An intention-to-treat comparison of overall KESS, GIQLI, Wexner, USP and SF36 scores did not reveal significant differences between the two arms 5 years postoperatively. Statistically significant improvement was observed shortly after surgery with no further improvement or impairment recorded 1–5 years postoperatively. During the 5-year follow-up, additional surgical procedures were performed in 25.9% versus 28.6% of patients who had undergone excision or resection (P = 0.80), respectively. LIMITATIONS, REASONS FOR CAUTION The presumption of a 40% difference concerning postoperative functional outcomes in favour of nodule excision resulted in a lack of power for demonstration of the primary endpoint difference. WIDER IMPLICATIONS OF THE FINDINGS Five-year follow-up data do not show statistically significant differences between conservative and radical rectal surgery for long-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was received. Patient enrolment and follow-up until 2 years postoperatively was supported by a grant from the clinical research programme for hospitals in France. The authors declare no competing interests related to this study. TRIAL REGISTRATION NUMBER This randomized study is registered with ClinicalTrials.gov, number NCT 01291576. TRIAL REGISTRATION DATE 31 January 2011. DATE OF FIRST PATIENT’S ENROLMENT 7 March 2011.

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

STUDY QUESTION Is there a difference in functional outcomes and recurrence rate between conservative versus radical rectal surgery in patients with large deep endometriosis infiltrating the rectum 5 years postoperatively? SUMMARY ANSWER No evidence was found that long-term outcomes differed when nodule excision was compared to rectal resection for deeply invasive endometriosis involving the bowel. WHAT IS KNOWN ALREADY Functional outcomes of nodule excision and rectal resection for deeply invasive endometriosis involving the bowel are comparable 2 years after surgery. Despite numerous previously reported case series enrolling patients managed for colorectal endometriosis, long-term data remain scarce in the literature. STUDY DESIGN, SIZE, DURATION From March 2011 to August 2013, we performed a two-arm randomized trial, enrolling 60 patients with deep endometriosis infiltrating the rectum up to 15 cm from the anus, measuring >20 mm in length, involving at least the muscular layer in depth, and up to 50% of rectal circumference. Among them, 55 women were enrolled at one tertial referral centre in endometriosis, using a randomization list drawn up separately for this centre. Institute review board approval was obtained to continue follow-up to 10 years postoperatively. One patient requested to stop the follow-up 2 years after surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients underwent either nodule excision by shaving or disc excision, or segmental resection. Randomization was performed preoperatively using sequentially numbered, opaque, sealed envelopes, and patients were informed of randomization results. The primary endpoint was the proportion of patients experiencing one of the following symptoms: constipation (1 stool/>5 consecutive days), frequent bowel movements (≥3 stools/day), anal incontinence, dysuria or bladder atony requiring self-catheterization 24 months postoperatively. Secondary endpoints were values taken from the Knowles–Eccersley–Scott-symptom questionnaire (KESS), the gastrointestinal quality of life index (GIQLI), the Wexner scale, the urinary symptom profile (USP) and the Short Form 36 Health Survey (SF36). MAIN RESULTS AND THE ROLE OF CHANCE Fifty-five patients were enrolled. Among the 27 patients in the excision arm, two were converted to segmental resection (7.4%). One patient managed by segmental resection withdrew from the study 2 years postoperatively, presuming that associated pain of other aetiologies may have jeopardized the outcomes. The 5 year-recurrence rate for excision and resection was 3.7% versus 0% (P = 1), respectively. For excision and resection, the primary endpoint was present in 44.4% versus 60.7% of patients (P = 0.29), respectively, while 55.6% versus 53.6% of patients subjectively reported normal bowel movements (P = 1). An intention-to-treat comparison of overall KESS, GIQLI, Wexner, USP and SF36 scores did not reveal significant differences between the two arms 5 years postoperatively. Statistically significant improvement was observed shortly after surgery with no further improvement or impairment recorded 1–5 years postoperatively. During the 5-year follow-up, additional surgical procedures were performed in 25.9% versus 28.6% of patients who had undergone excision or resection (P = 0.80), respectively. LIMITATIONS, REASONS FOR CAUTION The presumption of a 40% difference concerning postoperative functional outcomes in favour of nodule excision resulted in a lack of power for demonstration of the primary endpoint difference. WIDER IMPLICATIONS OF THE FINDINGS Five-year follow-up data do not show statistically significant differences between conservative and radical rectal surgery for long-term functional digestive and urinary outcomes in this specific population of women with large involvement of the rectum. STUDY FUNDING/COMPETING INTEREST(S) No specific funding was received. Patient enrolment and follow-up until 2 years postoperatively was supported by a grant from the clinical research programme for hospitals in France. The authors declare no competing interests related to this study. TRIAL REGISTRATION NUMBER This randomized study is registered with ClinicalTrials.gov, number NCT 01291576. TRIAL REGISTRATION DATE 31 January 2011. DATE OF FIRST PATIENT’S ENROLMENT 7 March 2011.

Background:. Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area. Methods:. The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention. Results:. The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up. Conclusion:. The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.

IF 2.766; International audience; IntroductionTo reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet, few series have reported outcomes after abdominal wall repair (AWR) using such meshes. Permacol is an acellular porcine dermal collagen matrix with a cross-linked pattern. This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol.Materials and methodsAll consecutive patients undergoing single-stage open AWR using Permacol mesh at eight university hospitals were included. Mortality, complication and hernia recurrence rates were assessed. Independent risk factors for complications and hernia recurrence were identified with logistic regression and Fine and Gray analysis, respectively.ResultsOverall, 250 patients underwent single-stage AWR with Permacol. Nearly 80% had a VHWG grade 3 or 4 defect. In-hospital mortality and complication rates were 4.8% (n = 12) and 61.6% (n = 154), respectively. Reintervention for complications was required for 74 patients (29.6%). Mesh explantation rate was 4% (n = 10). Independent risk factors for complications were smoking, defect size and VHWG grade. After a mean follow-up time of 16.8 months (± 18.1 months), 63 (25.2%) experienced hernia recurrence. One-, 2- and 3-year RFS were 90%, 74% and 57%, respectively. Previous AWR, mesh location and the need for reintervention were independent predictors of hernia recurrence.DiscussionSingle-stage AWR is feasible using Permacol. Mortality and complication rates are high due to patients’ comorbidities and the degree of contamination of the operative field. Given the observed recurrence rate, the benefit of biologics remains to be ascertained.

Drilling a re-entry well is a routine operation on mature fields. Several techniques are generally used for re-entry operations including cement plug sidetrack and whipstock sidetrack (Hussain et al. 2016). Often the completion string is pulled prior to performing the sidetrack operation but when it is not, one calls this operation a Through Tubing Rotary Drilling (TTRD). Benefits of TTRD wells include lower cost to access small hydrocarbon reserves. Through-tubing wells are usually drilled with small hole sizes and in Norway such wells are generally drilled with 5 7/8-in. or 5 ¾-in. hole sizes. In this paper we present the case of a through-tubing well drilled with an uncommon 3 ¾-in. hole size. This paper will: Present the reason for planning such a sidetrack: drilling 3 ¾-in. hole is a rare operation on the Norwegian Continental Shelf (NCS)Describe the solution selected for the operation, including the directional plan, the whipstock setting operation and the 3 ¾-in. bottom hole assemblySummarize the risks and compensating measures associated with this solution, including the low buckling margins in this well planned at inclinations higher than 90°, the low tolerances on the downhole connections that could lead to a twist-off, the limited experience with the directional behaviour of such a slim bottom hole assembly, the bit design.Present the results of the successful operation: this rare 3 ¾-in. hole drilled on the Norwegian Continental Shelf was drilled successfully and below budget.Find the main drivers that will make this solution portable to other situations This case study demonstrates how detailed and thorough planning based on modelling led to the successful delivery of a rare well design at first attempt. It is an objective of this paper to share some key elements that will be useful for the planning of similar operations in other wells in the future.

This case study aims to share the experience and improve the understanding of downhole shock and vibration and demonstrate how it can be prevented using thorough offset analysis, an advanced bit design, downhole mechanics module, and detailed drilling roadmap. The new approach delivered a step change in the performance of the 17 ½-in. section in Valemon field, in the Norwegian sector of the North Sea. Employing a one-run strategy through this extremely demanding section could eliminate the need for a dedicated motor run to withstand high shocks through the sandy interval with interbedded limestone and cemented sand layers. Using a point-the-bit bottomhole assembly (BHA) with a detailed drilling roadmap for every group of formations secured smooth drilling, pull out, and running of the intermediate 14-in. × 13 3/8 in. casing to provide integrity to drill 12 1/4-in. section. An advanced bit design balanced drilling with low aggressiveness through sand without compromising the performance through the interbedded limestone stringers and claystone. The conical-shaped cutter placed behind the main PDC conventional cutters successfully controlled the depth of cut through the sandy intervals and mitigated the downhole shocks. A detailed drilling roadmap was developed to define formation-specific drilling parameters to mitigate the shock-related failures on similar lithology. A downhole drilling mechanics module was used to provide real-time axial, lateral, and torsional shock and vibration data, which enabled adjustment of surface drilling parameters accordingly.

Background:. Tenets of chest wall reconstruction for malignancy are well known; however, the insertion of synthetic prosthetic material to achieve rigid and nonrigid skeletal reconstruction could be associated with more complications including infection and extrusion especially in high risk patients. This includes fungating, infected tumors, previous radiotherapy, scars, smoking, diabetes, and morbid obesity. Bioprosthesis Acelluar Dermal Matrix Strattice would be a substitute to resist infection and provide stable coverage. Methods:. A retrospective data analysis study on 8 high-risk patients who underwent chest wall resection and reconstruction with bioprosthesis (Strattice) with/without titanium plates in the period between 2012 and 2017 was performed. Patient’s demographics, risk factors, clinico-pathological, radiological, operative details, adjuvant therapy, postoperative morbidity, and follow-up data were recorded. Results:. Sarcoma was the pathology in 7 and recurrent breast cancer in 1 with age range from 21 to 71 years (mean, 50) and preponderance of female patients (n = 5). Defects were located anterior/anterolateral with size ranging from 270 to 1,050 cm2 (mean, 511). Reconstruction was performed using Strattice only in 4 patients, whereas in 4 it was combined with titanium plates. All patients required flap reconstruction (3 pedicled and 5 free). The follow-up ranged from 9 to 52 months (mean, 24.8). Minor complications occurred in 2 patients; however, good functional outcome was achieved in all. Conclusion:. Strattice would act as a safe alternative modality for chest wall reconstruction to resist infection in high-risk patients with extensive defects. It should be considered as a valuable tool in the armamentarium of chest wall reconstruction.

Purpose Reconstruction after sternal resection is performed according to surgeon intuition; physiologic evidence for selection of prostheses is lacking. We present our experience of the in vivo function of a novel device for sternal reconstruction. Description A three-dimensional–printed titanium and porous polyethylene sternal prosthesis was made according to the patient's computed tomographic scan. The titanium arms slot over adjacent ribs and are fixed in place with screws. The porous element allows ingrowth of native tissue while preventing lung herniation around the narrow titanium bars. Evaluation We performed optoelectronic plethysmography to assess the physiologic function of the device compared with a muscle flap reconstruction. Asynchronous and paradoxical movements of the thoracoabdominal surface were apparent with the muscle flap reconstruction but not with the new device. Considerably higher tidal volumes and a lower respiratory rate achieved the same minute volume with the new device compared with the muscle flap. Conclusions Rigid sternal reconstruction with a three-dimensional–printed prosthesis demonstrated superior respiratory mechanics compared with reconstruction with an autologous muscle flap.

Rathole elimination (RHE) BHA comprised of hydraulics and ball-drop underreamer has been used in different North Sea fields. RHE success has been very important for operators in completion, cementing, casing running optimization, and handling contingencies by running intermediate liners and casings. One of the major benefits of the RHE system is time saving because the rathole is removed in the same drilling run and the dedicated underreaming run is not required. In today's field operations, this time saving has become considerably important on the older platforms as well. An RHE system has been successfully run on the North Sea continental shelf (NCS) with five different operators and in six challenging fields, resulting in significant time and cost saving for each operator. BHA and hydraulics design are the basis of these successful RHE operations. Starting from a vertical well to whipstock exits and 2D wells followed by 3D complex wells have established that the RHE system is fully directional and steering capability is not compromised by BHA complexity. Suites of applications, including the integrated dynamic design and analysis 4D platform was used for BHA optimization and stability, underreamer and bits cutting structure selection, and directional response prediction. Both push-the-bit and point-the-bit rotary steerable systems (RSS) have been used in these operations. RHE showed great success and technology maturity on NCS in various borehole sizes. This paper presents the historical run summaries and the technology maturity life cycle in the North Sea.

Although the preoperative management of mild and moderate (Grade I–II) acute calculous cholecystitis (ACC) has been standardized, there is no consensus on the value of abdominal drainage after early cholecystectomy. In a post hoc analysis of a randomized controlled trial (NCT01015417) focused on the value of postoperative antibiotic therapy in patients with ACC, we determined the value of abdominal drainage in patients having undergone laparoscopic cholecystectomy for Grades I–II ACC. All postoperative complications were analyzed after using a propensity score. A post hoc test was used to assess the statistical robustness of our results. Of the 414 enrolled patients, 178 did not have abdominal drainage (forming the no-drainage group) and 236 had drainage (the drainage group). After matching on PS, the deep incisional site infection was 1.1 versus 0.8 %, p = 0.78. This result is similar for the superficial incisional site infections; the distant infections; the overall morbidity, and the readmission rate. Only the hospital length of stay was significantly longer in the drainage group (3.3 vs. 5.1 days, p = 0.003). Neither abdominal drainage nor the absence of postoperative antibiotic therapy was found to be a risk factor for deep incisional site infections. The use of abdominal drainage depends on the surgeon’s personal preferences but is often used in high-risk populations. However, abdominal drainage does not appear to be of any benefit (in terms of postoperative outcomes) and may even compromise recovery in patients having undergone early laparoscopic cholecystectomy for mild or moderate ACC.

The objective of this paper is to share the results obtained from in-depth analysis using a down hole mechanics and dynamics monitoring sub, which lead to the first successful Gullfaks Satellite 14 ¾ x 17 ½ -in Rathole elimination operation through challenging lithology. Shallow gas is encountered in the Gullfaks South area at a true vertical depth of between 335-339m (from MSL), and a casing design incorporating a 16-in liner is utilized to isolate this interval. A 14 ¾ x 17 ½ -in section is then drilled to isolate weak and unstable formations, and in all previous wells this section was drilled with a two run strategy. The first run to drill to section target depth (TD) while hole opening, followed by a dedicated second run to open the rathole. An opportunity was identified to improve well construction performance by eliminating the dedicated run to open the rat-hole, and tailoring the bit design to overcome the challenging lithology and high levels of shock and vibration seen on offset wells. Detailed pre-job planning and BHA design analysis was combined with new downhole technologies to overcome these challenges. Dual reamers were used within a Rotary Steerable System (RSS) BHA to drill the 14 ¾ x 17 ½ -in section and eliminate the rat-hole in one run. This innovative approach involved drilling to section target depth (TD) using an upper ball drop reamer, tool positioned 45 meters behind the bit for hole enlargement while drilling, and then pulling back to position the bit at rat-hole shoulder. At this point the upper reamer was de-activated and a lower on demand hydraulically activated reamer, mounted directly above the RSS was opened to eliminate the rat-hole. Due to excessive shocks & vibrations experienced on offset wells, a down hole drilling mechanics & dynamics sub was utilized to provide real-time information about downhole forces and BHA motions, combined with a tailored bit design to control depth of cut in sandy intervals. This unprecedented approach resulted in 2.5 days saving.

The main objective of this paper is to share the experience of the first Dual reamer bottom hole assembly (BHA) design implemented off-shore Norway, Gullfaks field, 17 ½ × 20-inch section. It presents the drilling challenges, innovative bottom hole assembly and the first world wide application for the Electro-magnetic receiver sub fully integrated with rotary steerable system (RSS) Hole enlargement while drilling (HEWD) became a well-known application, and they are widely used to support several well intervention objectives like; i) Accommodating un-common casing design. ii) Reduce operational risk such as high equivalent circulating density (ECD). iii) Optimized casing and completion programs. There are two main types on hole enlargement tools, based on activation mechanism: ball-drop using a ball to Activate/De-activate the reamer, and hydraulic on demand triggered by changing flow rate on a predefined specific range, so called ‘Indexing’ for Activation/De-activation of the reamer. Both carrying a common implicit risks and limitations, where reamers have to be positioned above logging while drilling tools (LWD) so that the enlarged hole does not impair the quality of the formation evaluation measurements, or compromise the bottom hole assembly stabilization. This results in a rat-hole of 40-50 meters at the section target depth (TD), consequently challenges the casing running, casing cementing job, and drilling next sections with potential risk of cement pack-off around bottom hole assembly. Today in the industry, these challenges are usually addressed by an extra dedicated run for opening the rat-hole. Collaborative efforts between operator in the North-sea and a Service Company to address the risk and limitations associated to the hole enlargement while drilling design. Dual Reamer System developed to reduce the rat-hole length to minimum instead of 40-50 meters, and to eliminate the extra dedicated run for opeing the rat-hole. The innovative approach planned to drill to section target depth (TD) using upper ball drop reamer, tool positioned 45 meters behind the bit for Hole Enlargement While Drilling, then pull back to position the bit at rat hole shoulder, de-activate upper reamer (ball drop system), and activate the lower hydraulic on demand reamer to eliminate the rat-hole. A Gyro while drilling integrated into the BHA along with 9-in world first electro-magnetic receiver sub mounted on the top of the hydraulic on demand reamer. Providing a full integration, and securing a real time communication with the RSS in a critical and challenging Anti-collision situation. The unprecedented approach successfully implemented on Gullfaks field, 17 ½ × 20-inch section drilled to target depth (TD) in one run, with all objectives met on directional control in tight Anti-collision scenario, and measurements and logging while drilling. The Dual reamer BHA along with the Electro-magnetic receiver sub proven efficient steering capability and reliability, which led to significant improvement in the drilling, casing running and cementing operations

Soft-tissue reconstruction for isolated heel defects represents a challenging surgical dilemma due to tight inelastic tissue and inevitable acute angulations of the fibro-vascular pedicle of local flaps. A modified pedicled flap with a tongue-like skin extension has been designed to eliminate tunnel tightness to avoid traction injury and kinking of the blood vessel. Between 2003 and 2005, eight patients with isolated heel defects were analysed (six men, two women). Their age ranged from 5 to 47 years (median age = 31). Six were traumatic while two were neuropathic. Reversed sural (n = 4), medial planter (n = 3) and one dorsalis pedis artery fasciocutaneous flap were used. The average follow-up period was 1 year during which the flaps were monitored for venous congestion, ischemia, superficial epidermolysis and partial or total flap loss. Only one modified pedicle flap showed mild venous congestion; on the other hand, no other ischemic events such as superficial epidermolysis or flap loss were experienced. The modified tongue-like process extension is considered a valuable tool to increase the versatility of these flaps.

Supplemental Digital Content is available in the text., Summary: The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction.To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction.One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded.Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome.The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.Même si la réduction mammaire par patron de Wise est l’une des interventions les plus prévalentes pour assurer une réduction cutanée satisfaisante, elle se fait aux dépens de complications plus longues et inévitables des cicatrices et des plaies, particulièrement à la jonction en T inversée.Décrire une technique novatrice sans fermeture de tension à la jonction en T par lambeaux lipodermiques triangulaires. L’objectif consiste à soulager la tension cutanée, réduisant ainsi la nécrose cutanée, la déhiscence et la cicatrisation excessive à la jonction en T.Entre 2009 et 2013, 173 interventions consécutives ont été exécutées auprès de 137 patients. Les données colligées incluent la démographie, la morbidité périopératoire et le poids des tissus mammaires réséqués. La période de suivi durait de trois à 30 mois. Les complications postopératoires précoces et tardives et la satisfaction des patients ont été enregistrées.Huit interventions (4,6 %) se sont associées à une épidermolyse superficielle sans déhiscence de la jonction en T, tandis que cinq (2,9 %) ont donné lieu à une déhiscence pleine épaisseur de la plaie. Ainsi, 94 % des patients étaient pleinement satisfaits des résultats.La technique est sécuritaire, polyvalente et facile à exécuter, assure une zone sans tension et agit comme une attelle dermique interne, ce qui entraîne une meilleure cicatrisation de la plaie, aux résultats esthétiques plus favorables, qui maintient la projection mammaire.

This works aim is to evaluate the efficacy of skin grafts and flaps in reconstruction of post-burn hand and wrist deformities. A prospective study of 57 burn contractures of the wrist and dorsum of the hand was performed. Flaps were used only if there was a non-vascularized structure after contracture release, otherwise a skin graft was used. Active range of motion (ROM) was used to assess hand function. The extension deformity cohort uniformly underwent skin graft following contracture release with a mean improvement of 71 degrees (p0.0001). The flexion deformity cohort was treated with either skin grafts (8 patients) or flaps (9 patients) with a mean improvement of 44 degrees (p0.0001). Skin grafts suffice for dorsal hand contractures to restore functional wrist ROM. For flexion contractures, flaps were more likely for contractures6 months. Early release of burn contracture is advisable to avoid deep structure contracture.

Background:This study is a part of the IFCC-global study to derive reference intervals (RIs) for 28 chemistry analytes in Saudis.Method:Healthy individuals (n=826) aged ≥18 years were recruited using the global study protocol. All specimens were measured using an Architect analyzer. RIs were derived by both parametric and non-parametric methods for comparative purpose. The need for secondary exclusion of reference values based on latent abnormal values exclusion (LAVE) method was examined. The magnitude of variation attributable to gender, ages and regions was calculated by the standard deviation ratio (SDR). Sources of variations: age, BMI, physical exercise and smoking levels were investigated by using the multiple regression analysis.Results:SDRs for gender, age and regional differences were significant for 14, 8 and 2 analytes, respectively. BMI-related changes in test results were noted conspicuously for CRP. For some metabolic related parameters the ranges of RIs by non-parametric method were wider than by the parametric method and RIs derived using the LAVE method were significantly different than those without it. RIs were derived with and without gender partition (BMI, drugs and supplements were considered).Conclusions:RIs applicable to Saudis were established for the majority of chemistry analytes, whereas gender, regional and age RI partitioning was required for some analytes. The elevated upper limits of metabolic analytes reflects the existence of high prevalence of metabolic syndrome in Saudi population.

The Gullfaks field was discovered in 1979 and has been developed via three production platforms. To meet objectives the well designs require 20-in. and/or 17 ½-in. hole sections drilled to high angle (50° to 80° inclination), through the Utsira and Sotra formations and into the top of the Stord. The Sotra member within the Hordaland group, contains intervals of claystone and sandstone with a significant strength contrast, some thin intervals of dolomite may also be present. Performance under-reaming-while-drilling the 20-in. section has been variable, typically requiring between two to four bit runs due to cutting structure, drillstring and downhole tool failures. In an attempt to fully evaluate the downhole drilling environment, a new technology providing a comprehensive suite of advanced real-time and recorded-mode measurements of the drilling process was introduced. This information was used in the execution phase with remote interpretation support from drilling analysts. The higher resolution recorded data were analyzed in detail and used to calibrate models of the drilling process. The information obtained enhanced understanding of the Sotra formation and the downhole behavior of the drilling system. This increased understanding resulted in changes to operational procedures and bottom hole assembly design, which reduced the risk of drillstring and downhole tool failures. For the first time this hole section was drilled in one bit run, validating the feasibility of this approach, which was then transferred into the hole opening while drilling operations within a satellite field. Examples are included with novel insight into the response of under-reaming assemblies as the reamer encounters formation changes, an in-depth analysis of the static and dynamic loads placed on the bottom hole assemblies, and the impact of refinements to drilling procedures.

Management of the complex abdominal wall defect after tumour extipiration represents a challenge and requires careful planning. We report a case of a 76-year-old gentleman treated initially for a T4N0M0 Dukes B sigmoid cancer with anterior resection in 2008. He re-presented 6 months after chemotherapy with a histopathologically proven anterior abdominal wall adenocarcinoma of colonic origin with involvement of the underlying parietal wall and rectus muscle. En bloc resection was undertaken with the harvesting of a vertical myocutaneous gracilis, VMG, pedicled flap (11 × 22 cm) to fill the abdominal soft tissue defect. A concurrent supraumbilical incisional hernia, poor coverage from other local pedicle flap options and multiple co-morbidities made the pedicled VMG the only viable option. We report its success as a valuable option in the reconstructive armamentarium for complex abdominal defects.

Phosphaturic mesenchymal tumour is an extremely rare mesenchymal neoplasm of bone or soft tissue. It is associated with paraneoplastic oncogenic osteomalacia through secretion of fibroblast growth factor-23 (FGF-23) which inhibits renal proximal tubule phosphate re-uptake. We report a case of a 36-year-old woman with a large chest wall tumour completely excised by extensive chest wall resection and reconstruction with polypropylene mesh–methylmethacrylate composite and pedicled muscle flaps.

We report a case of a 35-year-old woman who presented with post-burn neck scar contracture with massive scarring of the neck and lower face. The initial step was to release the contracture with excision of the scar tissue together with coverage of the resultant defect with a latissmus dorsi musculocutaneous flap. Six months later, we implanted a round tissue expander underneath the flap with steady cautious expansion over the following 7 months to almost double the original flap dimensions to achieve an additional replacement of the scar tissue over the upper neck and lower face.

Resume La perforation d’un cancer rectal est habituellement intraperitoneale. Une perforation sous-peritoneale est rare et decouverte souvent tardivement par une infection perineale severe, necessitant un diagnostic rapide et une prise en charge chirurgicale immediate associee a une antibiotherapie. Nous rapportons le cas d’un patient presentant une perforation d’un cancer rectal revelee par une fasciite necrosante de la cuisse droite.

AIM: To investigate recurrence rates, patterns and complications after nonoperatively managed complicated diverticulitis (CD). METHODS: A retrospective study of patients treated for CD was performed. CD was defined on computed tomography by the presence of a localized abscess, pelvic abscess or extraluminal air. For follow-up, patients were contacted by telephone. Numbers of elective surgeries, recurrences and abdominal pain were analyzed. RESULTS: A total of 114 patients (median age 57 years (range 29-97)), were admitted for CD. Nine patients required surgical intervention for failure of conservative therapy (Hartmann’s procedure: n = 6; resection and colorectal anastomosis: n = 3). Of the 105 remaining patients, 24 (22.9%) underwent elective sigmoid resection. The 81 (71%) non-operated patients were all contacted after a median follow-up of 32 mo (4-63). Among them, six had developed a recurrent episode of diverticulitis at a median follow-up of 12 mo (6-36); however, no patient required hospitalization. Sixty-eight patients (84%) were asymptomatic and 13 (16%) had recurrent abdominal pain. CONCLUSION: Conservative policy is feasible and safe in 71% of cases, with a low medium-term recurrence risk.

Supplemental Digital Content is available in the text., Background: Management of complex thoracic defects post tumor extipiration is challenging because of the nature of pathology, the radical approach, and the insertion of prosthetic material required for biomechanical stability. Wound complications pose a significant problem that can have detrimental effect on patient outcome. The authors outline an institutional experience of a multidisciplinary thoracic oncoplastic approach to improve outcomes. Methods: Prospectively collected data from 71 consecutive patients treated with chest wall resection and reconstruction were analyzed (2009–2015). The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection were recorded. All patients were managed in a multidisciplinary approach to optimize perioperative surgical planning. Results: Pathology included sarcoma (78%), locally advanced breast cancer (15%), and desmoids (6%), with age ranging from 17 to 82 years (median, 42 years) and preponderance of female patients (n = 44). Chest wall defects were located anterior and anterolateral (77.5%), posterior (8.4%), and apical axillary (10%) with skeletal defect size ranging from 56 to 600 cm2 (mean, 154 cm2). Bony reconstruction was performed using polyprolene mesh, methyl methacrylate prosthesis, and titanium plates. Soft tissue reconstructions depended on size, location, and flap availability and were achieved using regional, distant, and free tissue flaps. The postoperative follow-up ranged from 5 to 70 months (median, 32 months). All flaps survived with good functional and aesthetic outcome, whereas 2 patients experienced surgical site infection (2.8%). Conclusions: Multidisciplinary thoracic oncoplastic maximizes outcome for patients with large resection of chest wall tumors with reduction in surgical site infection and wound complications particularly in association with rigid skeletal chest wall reconstruction.

Current management of N0 stage lip Squamous Cell Carcinoma (SCC) are prophylactic neck dissection, radiotherapy, or "watch and see" policy. The aim is the evaluation of the role of sentinel lymph node biopsy (SLNB) in their management based upon actual and not hypothetical presence of cervical lymph node (CLN) micrometastases as a same day procedure. Fourteen patients between November 2003 and August 2005 were included, nine men and five women, median age:57 years, (range 34-65 years). SLNB using preoperative lymphoscintigraphy and intra-operative localisation with patent blue and radioactive Tc(99m) Human Serum Albumin was performed. The median follow-up period was 26 months. Successful patent blue localisation in 13/14 whilst successful radio-localisation in all patients. Micrometastases were detected in 1/14 whom underwent therapeutic neck dissection. No local recurrence or regional lymph node involvement were detected. SLNB is a technically feasible and accurate approach for detection of CLN micrometastases in N0 stage lip SCC using the triple diagnostic localisation technique as a same day procedure.

S S29 P004. Management of partial breast defects following breast conserving surgery in patients with previous augmentation mammoplasty Haitham Khalil, Amr Elshayeb 1 Heart of England NHS Foundation Trust, Birmingham, West Midlands, UK 2 Faculty of Medicine, Cairo University, Cairo, Egypt Introduction: The efficacy of breast-conserving surgery (BCS) for the local control of early breast cancer has been repeatedly evidenced. The incidence of breast cancer in women with implants is increasing and will continue to do so for the foreseeable future due to the marked increase in breast implant insertion in recent years. Undoubtedly, the clinical management of such patients may be difficult, as aesthetic results are likely to be a major concern for women who have already undergone cosmetic surgery to the breast. There is no consensus on surgical approach to this scenario. Patients and methods: Between 2009 and 2014. Fifty patients with previous bilateral augmentation mammoplasty were diagnosed with early breast cancer and treated with Wide Local Excision (WLE). The predominant pathology was DCIS (85%). The mean greatest tumour dimension was 1.32cm. Out of the 50 patients 11 patients their histopathology revealed microscopically positive margins, necessitates removal of implant during the WLE procedure. 7 patients (63.3%) with sub-glandular implant and 4 patients (36.3%) with retro muscular implant. 72% of cases their tumour was in the upper outer quadrant of the breast. WLE sites were not drained, nor deep re-approximation of breast tissue has been performed, the implant’s capsule was not resected unless it is involved with tumour tissue. There were no local nor systemic recurrence in all patients, at the time of the completion of this study. There was no correlation between postoperative adjuvant therapy and aesthetic outcome. The partial breast defect & contralateral symmetry represent a reconstructive challenge. The reconstructive techniques used in the 11 patients varied from muscle sparing Latissimus Dorsi (LD), implant based mastopexy, and lipofilling mammoplasty. The cosmetic outcome after breast reconstruction & contralateral symmetry were evaluated using patient’s satisfaction questionnaires during their follow up visits. Results: Satisfactory aesthetic results were achieved in 9 (81.8%) out of 11 patients without significant clinical complications. Conclusion: Breast conservative surgery can result in an unacceptable aesthetic outcome in previously augmented breasts. Each deformity must be assessed on an individual base. The availability of a range of reliable techniques could allow achievement of optimal results and symmetry with the contralateral breast. However, the supreme aim is to ensure oncological safety margins. http://dx.doi.org/10.1016/j.ejso.2015.03.040 005. An audit of Acellular Dermal Matrix (ADM) assisted breast reconstruction procedures e Are antibiotics unavoidable? Mario Metry, Robert Thomas, Magdy Youssef, Neil Mclean, Paola Serra, Michael Carr Northumbria Healthcare, Northumberland, UK Introduction: The use of ADM grafts in breast reconstruction has been widely adopted in the UK. Following the National Mastectomy and Breast Reconstruction Audit, joint guidelines from ABS and BAPRAS were published in 2013 with regards to the use of ADMs in breast reconstruction. The aim is to audit clinical outcomes in our district general unit against these guidelines. Methods: Data was collected retrospectively from medical records over a one-year period. Indications; cautions; surgical technique; postoperative infection; implant loss; patient reported outcome measures; unit and organisation criteria were recorded. Results: 23 consecutive patients were included. Median age was 52 years (40e69); Median BMI 24 (18.5e43). 14 (60.8%) had immediate reconstruction with expander or dual chamber implant, 5 (21%) had delayed 2nd stage reconstruction and 4 patients (17.3%) had risk-reducing mastectomy. There was 0% return to theatre for local complications; target