Invasive lobular carcinoma (ILC) accounts for 5-15% of breast cancers. In comparison to other types of breast cancer, ILC is more likely to be associated with multifocal and contralateral breast involvement as well as a tendency to a diffuse infiltrative growth pattern which can represent a diagnostic challenge. The National Institute of Clinical Excellence guidelines in 2009 recommended the use of magnetic resonance imaging (MRI) in the preoperative assessment of ILC. This study aims to assess compliance with the guidelines in two District General Hospitals and the utility of MRI in the investigation of ILC. All cases of ILC between 2011 and 2013 were retrospectively identified from the pathology database and their breast imaging findings, pathology report, and operative intervention were reviewed. A total of 126 patients were identified with ILC, of these 46 had MRI preoperatively (36.5%). MRI upgraded mammography/ultrasound diagnoses in 10 patients (21.7%). MRI showed multicentric unilateral disease in 17 patients (37.0%) occult on ultrasound/mammogram, with these patients undergoing mastectomy and 16/17 (94.1%) confirmed multifocality on pathology. MRI showed a contralateral lesion in 9 patients (19.6%), four (8.7%) of which were malignant and had bilateral surgery, and five (10.9%) were benign on further imaging/biopsy. MRI also downgraded three patients (6.5%) to unifocal disease with reported multifocal appearances on mammography/ultrasound, and these patients underwent breast-conserving surgery. MRI adds significant additional information to mammograms/ultrasound in ILC and should be undertaken in all such cases preoperatively assuming no contraindication.

Aims It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery. Methods A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis. Results A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores. Conclusion Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618–630.

Aim: To determine the earliest time point at which anastomotic leaks can be detected in patients undergoing total colectomy (TC) with primary ileorectal anastomosis (IRA) for Familial Adenomatous Polyposis (FAP).Method: A case-controlled study of 10 anastomotic leak patients versus 20 controls following laparoscopic TC with IRA for FAP (from 96 consecutive patients between [2006][2007][2008][2009][2010][2011][2012][2013]. Panel timeseries data regression was performed using a double subscript structure to include both variables. A generalized least squares multi-variate approach was applied in a random effects setting to calculate correlations for observations, with anastomotic leak being the dependent variable. Univariate and multivariate regression calculations were then performed according to individual observations at each recorded time point. Time-series analysis was used to determine when a variable became significant in the leak group.Results: Multivariate analysis identified a significant difference between leak and control groups in mean heart rate (p=<0.001), mean respiratory rate (p=0.017), and mean urine output (p=0.001). Timepoint analysis showed that heart rate was significantly different between leak and control groups at post-operative day 4.25. Multivariate analysis identified a significant difference between groups in ALT (p=0.006), Bilirubin (p=0.008), Creatinine (p=0.001), Haemoglobin (p=<0.001), and Urea (p=0.007). There were no differences between groups with regards to markers of inflammation such as albumin, white blood cell count, neutrophil count, and CRP. Accepted ArticleThis article is protected by copyright. All rights reserved.Conclusion: Anastomotic leaks can be detected early (within 4.5 days of surgery) through changes in physiological, blood test, and observational parameters, providing an opportunity for early intervention in these patients to salvage the anastomosis. What does this paper add to the literature?The findings of this study suggest that anastomotic leaks can be detected within 4.5 days of surgery through changes in physiology, blood tests, and observational parameters. This is in contrast to the traditionally held view that leaks are detected after the fifth post-operative day.