Technical considerations for prophylactic mastectomy in patients at high risk for breast cancer

Article Abstract:

Patients at high risk for breast cancer may undergo mastectomy (breast removal) of a normal breast to prevent the development of breast cancer. There is controversy over the extent of the mastectomy necessary to achieve this preventive effect. Most often, the surgery performed is subcutaneous mastectomy, a procedure which leaves about 5 percent of the breast tissue in place (some glandular tissue in the tail of the breast and under the nipple). This procedure gives a better cosmetic result than other approaches but has been associated with at least a 1 percent incidence of cancer, based on fairly brief periods of follow-up. A study was undertaken of five women (10 breast specimens) to determine the extent of surgery necessary to removal all breast tissue. All women were estimated to have a 30 to 50 percent chance of developing breast cancer within 10 years, and all wished to undergo prophylactic mastectomy. Each patient underwent bilateral total mastectomy, including excision of the nipple, with insertion of breast expanders. The expanders were gradually inflated postoperatively and patients subsequently underwent insertion of permanent breast prostheses. It was found that breast tissue is often left within the chest wall muscle (superficial pectoralis major); a layer of this muscle was removed in the last two patients to undergo surgery. Frozen section analysis of the surgical margins should be obtained during the operation. After an average of five years of follow-up, none of the patients have developed cancer. It is concluded that the total mastectomy procedure should include removing a layer of muscle and fascia, but the value of the operation in preventing breast cancer remains to be determined, and patients still should undergo yearly follow-up. (Consumer Summary produced by Reliance Medical Information, Inc.)

Prevention, Breast cancer, Mastectomy

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Abdominal trauma and diagnostic peritoneal lavage revisited

Article Abstract:

Abdominal trauma needs to be detected early in order to reduce morbidity, mortality and hospital costs. If the injury has caused internal bleeding that does not stop on its own, surgery is necessary to arrest the bleeding and repair the injured organs. One method of evaluating abdominal organ injury is the use of diagnostic peritoneal lavage (DPL), in which sterile fluid is introduced into the abdominal cavity and then removed; this lavage fluid is analyzed for evidence of bleeding and injury. Although DPL is highly sensitive (95 to 98 percent) in detecting red blood cells (RBC) in the fluid returned from the abdominal cavity, reliance on RBC count alone results in a rate of unnecessary surgery ranging from 13 to 28 percent. White blood cell (WBC) count in the peritoneal fluid is a more reliable indicator of the need for surgery. This is especially true in identifying hollow visceral injury, which is not easily found using computed tomographic scan or ultrasound study. However, WBC response may give false-negative responses when done early, specifically less than an hour after injury. The timing of the DPL is important; it is suggested that this be performed no earlier than 3 hours after the injury. There must be a protocol established within the laboratory for handling the lavage fluid; if the sample is not properly mixed, a falsely high or low count of blood cells will be obtained. (Consumer Summary produced by Reliance Medical Information, Inc.)

Injuries, Medical examination, Abdomen, Irrigation (Medicine), Abdominal injuries, Peritoneal cavity, Peritoneal lavage

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Penetration of prophylactic antibiotics into peritoneal fluid

Article Abstract:

The use of cephalosporin antibiotics in the peritoneal fluid of the abdominal cavity to ward off infection was studied. Forty-six patients awaiting abdominal surgery were randomly assigned to one of three groups. Upon being called to the operating room, each patient was given one gram of an antibiotic, either cefazolin, cefuroxime or ceftazidime. Samples of the peritoneal fluid and the blood were taken after the abdominal cavity was opened for surgery. The concentration of cefazolin in the blood was the highest. High levels of all three antibiotics were found in the peritoneal fluid, but their effects against common disease-causing microorganisms of the intestines varied considerably. Cefazolin is the only drug studied that possesses marginal ability to fight Streptococcus faecalis, a type of bacteria common in feces that is generally resistant to cephalosporin antibiotics. Thus more recently developed cephalosporins are not more effective at preventing infection than the older cefazolin.

Analysis, Antibiotics, Cephalosporins, Cefuroxime, Body fluids, Ceftazidime

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