Paravertebral nerve block has the potential to offer long-lasting pain relief and few postoperative side effects when used for breast surgery. We demonstrated that paravertebral nerve block, when compared with general anesthesia, is an alternative technique for breast surgery that may offer pain relief superior to general anesthesia alone.

In this study we evaluated the efficacy of electro-acupoint stimulation, ondansetron versus placebo for the prevention of postoperative nausea and vomiting (PONV). Patients undergoing major breast surgery under general anesthesia were randomized into active electro-acupoint stimulation (A), ondansetron 4 mg IV (O), or sham control (placement of electrodes without electro-acupoint stimulation; placebo [P]). The anesthetic regimen was standardized. The incidence of nausea, vomiting, rescue antiemetic use, pain, and patient satisfaction with management of PONV were assessed at 0, 30, 60, 90, 120 min, and at 24 h. The complete response (no nausea, vomiting, or use of rescue antiemetic) was significantly more frequent in the active treatment groups compared with placebo both at 2 h (A/O/P = 77%/64%/42%, respectively; P = 0.01) and 24 h postoperatively (A/O/P = 73%/52%/38%, respectively; P = 0.006). The need for rescue antiemetic was less in the treatment groups (A/O/P = 19%/28%/54%; P = 0.04). Specifically, the incidence and severity of nausea were significantly less in the A group compared with the other groups, and in the O group compared with the P group (A/O/P = 19%/40%/79%, respectively). The A group experienced less pain in the postanesthesia care unit, compared with the O and P groups. Patients in the treatment groups were more satisfied with their management of PONV compared with placebo. When used for the prevention of PONV, electro-acupoint stimulation or ondansetron was more effective than placebo with greater degree of patient satisfaction, but electro-acupoint stimulation seems to be more effective in controlling nausea, compared with ondansetron. Stimulation at P6 also has analgesic effects.

Summary This phase I dose-escalation trial evaluates the feasibility of single-dose preoperative partial breast irradiation delivered with external beam techniques in early stage breast cancer patients. No acute dose-limiting toxicity was observed at 15, 18, or 21Gy. Paired pre- and post-radiation imaging and tumor biopsies offer unique insight into the biology of breast cancer radiation response. Purpose Women with biologically favorable early stage breast cancer are increasingly treated with accelerated partial breast radiation (PBI). However, treatment-related morbidities have been linked to the large post-operative treatment volumes required for external beam PBI. Relative to external beam delivery, alternative PBI techniques require equipment that is not universally available. To address these issues, we designed a phase I trial utilizing widely available technology to 1) evaluate the safety of a single radiation treatment delivered preoperatively to the small-volume, intact breast tumor and 2) identify imaging and genomic markers of radiation response. Methods Women 55 or older with clinically node negative, ER+ and/or PR+, HER2-, T1 invasive carcinomas or low-intermediate grade in situ disease ≤2cm were enrolled (n=32). Intensity-modulated radiotherapy was used to deliver 15 Gy (n=8), 18 Gy (n=8), or 21Gy (n=16) to the tumor with a 1.5cm margin. Lumpectomy was performed within 10 days. Paired pre- and post-radiation MRI images and patient tumor samples were analyzed. Results No dose-limiting toxicity was observed. At a median follow-up of 23 months, there have been no recurrences. Physician-rated cosmetic outcomes were good/excellent and chronic toxicities were grade 1-2 (fibrosis, hyperpigmentation) in patients receiving preoperative radiation only. Evidence of dose-dependent changes in vascular permeability, cell density, and expression of genes regulating immunity and cell death were seen in response to radiation. Conclusions Preoperative single-dose radiotherapy to intact breast tumors is well-tolerated. Radiation response is marked by early indicators of cell death in this biologically favorable patient cohort. This study represents a first-step towards a novel PBI approach. Preoperative radiation should be tested in future clinical trials as it has the potential to challenge the current treatment paradigm and provide a path forward to identify radiation response biomarkers.

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The results of the sphincter pharyngoplasty were evaluated in 139 patients with velopharyngeal incompetence (VPI) who demonstrated active velar elevation. All patients underwent perceptual speech evaluation and lateral phonation radiographic study; select patients underwent multiview videofluoroscopic, flexible nasendoscopic, and pressure-flow studies. All but one patient demonstrated improvement and 109/139 (78.42%) demonstrated resolution of VPI. Sixteen of thirty failed pharyngoplasties were revised. Revision was successful in 8/16 patients yielding an overall success rate of 117/139 (84.17%). Success rate was 67.65 percent for patients managed during the first 5 years and improved to 84.78 percent for patients managed during the last 5 years of this 15-year series. Analysis revealed that younger patients were treated more successfully than older patients, large velopharyngeal areas were treated as successfully as smaller ones, and circular closure patterns were treated more successfully than coronal patterns. The primary cause of failure was insertion of the flap below the point of attempted velopharyngeal contact.

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the aut...

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