BackgroundRates of contralateral risk-reducing mastectomy (CRRM) are rising, despite a decreasing global incidence of contralateral breast cancer. Reasons for requesting this procedure are complex, and we have previously shown a variable practice amongst breast and plastic surgeons in England. We propose a protocol, based on a published systematic review, a national UK survey and the Manchester experience of CRRM.MethodsWe reviewed the literature for risk factors for contralateral breast cancer and have devised a 5-step process that includes history taking, calculating contralateral breast cancer risk, cooling off period/counselling, multi-disciplinary assessment and consent. Members of the multi-disciplinary team included the breast surgeon, plastic surgeon and geneticist, who formulated guidelines.ResultsA simple formula to calculate the life-time risk of contralateral breast cancer has been devised. This allows stratification of breast cancer patients into different risk-groups: low, above average, moderate and high risk. Recommendations vary according to different risk groups.ConclusionThese guidelines are a useful tool for clinicians counselling women requesting CRRM. Risk assessment is mandatory in this group of patients, and our formula allows evidence-based recommendations to be made.

BRCA1 and BRCA2 mutation carriers have an increased risk of contralateral breast cancer after primary breast cancer. Risk reduction strategies are discussed after assessment of risk factors for developing contralateral breast cancer. We assessed potential risk factors that could be of use in clinical practice, including the novel use of single nucleotide polymorphisms (SNP) testing. 506 BRCA1 and 505 BRCA2 mutation carriers with a diagnosis of breast cancer were observed for up to 30 years. The risk of a contralateral breast cancer is approximately 2-3% per year, remaining constant for at least 20 years. This was similar in both BRCA1 and BRCA2 carriers. Initial breast cancer before age 40-years was a significant risk factor, which was more pronounced in BRCA1 patients. The effect of risk-reducing oophorectomy on contralateral breast cancer risk may be overestimated because of bias. No significant association was found between overall breast cancer risk SNP score and contralateral breast cancer development. Young mutation carriers, particularly those with BRCA1 mutations, who develop breast cancer have a significantly higher risk of developing contralateral breast cancer, remaining constant for over 20 years. Contralateral risk-reducing mastectomy should be considered in this group, in particular as there is a survival benefit. Caution is advised when counselling women considering risk-reducing oophorectomy as, after accounting for statistical bias, the associated risk reduction was found to be non-significant, and potentially smaller than has been previously reported. SNP testing did not add any further discriminatory information when assessing contralateral breast cancer risk.

HighlightsMulticentre prospective study involving breast and plastic surgical units across the UK.Will produce valuable data regarding the practice and outcomes of therapeutic mammaplasty.Will inform decision-making and lead to future definitive study.Will strengthen the collaborative network to facilitate the delivery of future projects.Will increase awareness of the techniques among trainees such that participation is educational.

Rates of contralateral risk-reducing mastectomy have increased substantially over the last decade. Surgical oncologists are often in the frontline, dealing with requests for this procedure. This paper reviews the current evidence base regarding contralateral breast cancer, assesses the various risk-reducing strategies, and evaluates the cost-effectiveness of contralateral risk-reducing mastectomy.

Contralateral risk-reducing mastectomy (CRRM) rates have tripled over the last 2 decades. Reasons for this are multi-factorial, with those harbouring a pathogenic variant in the BRCA1/2 gene having the greatest survival benefit. On May 14th, 2013, Angelina Jolie shared the news of her bilateral risk-reducing mastectomy (BRRM), on the basis of her BRCA1 pathogenic variant status. We evaluated the impact of this news on rates of CRRM in women with increased risk for developing breast cancer after being diagnosed with unilateral breast cancer. The prospective cohort study included all women with at least a moderate lifetime risk of developing breast cancer who attended our family history clinic (1987–2019) and were subsequently diagnosed with unilateral breast cancer. Rates of CRRM were then compared between patients diagnosed with breast cancer before and after Angelina Jolie’s announcement (pre- vs. post-AJ). Of 386 breast cancer patients, with a mean age at diagnosis of 48 ± 8 years, 268 (69.4%) were diagnosed in the pre-AJ period, and 118 (30.6%) in the post-AJ period. Of these, 123 (31.9%) underwent CRRM, a median 42 (interquartile range: 11–54) days after the index cancer surgery. Rates of CRRM doubled following AJ’s news, from 23.9% pre-AJ to 50.0% post AJ (p < 0.001). Rates of CRRM were found to decrease with increasing age at breast cancer (p < 0.001) and tumour TNM stage (p = 0.040), and to increase with the estimated lifetime risk of breast cancer (p < 0.001) and tumour grade (p = 0.015) on univariable analysis. After adjusting for these factors, the step-change increase in CRRM rates post-AJ remained significant (odds ratio: 9.61, p < 0.001). The AJ effect appears to have been associated with higher rates of CRRM amongst breast cancer patients with increased cancer risk. CRRM rates were highest amongst younger women and those with the highest lifetime risk profile. Clinicians need to be aware of how media news can impact on the delivery of cancer related services. Communicating objective assessment of risk is important when counselling women on the merits of risk-reducing surgery.

The aim of this current retrospective study was to assess postoperative mobility one year after above knee (AKA) or below knee amputation (BKA) in a district general hospital. Data on patient demographics, diabetic status, risks for peripheral vascular disease, mortality and mobility at one year were recorded from the vascular database. Seventy-five patients underwent lower limb amputation over a 70-month period (AKA n=31, BKA n=44). Operative mortality was 10% and mortality at one year 13.7%. Fourteen out of the 31 patients (45.1%) who underwent AKA were mobile independently or with a walking stick compared to 54.5% (24/44) in the BKA group (P=0.44). Fifteen patients (48.3%) were diabetic in the AKA group compared to 26 patients (59.1%) in the BKA group (P=0.49). In the under 60 years group and over 60 years group there was no significant difference in type of amputation (P=0.64) or mobility (P=0.69). In this current series, there was no significant rehabilitation benefits in patients undergoing BKA compared to AKA. With an ageing population who inherently have increasing significant medical problems, the perceived benefit in preserving the knee joint may not be as significant as previously reported.

Ann R Coll Surg Engl 2009; 91: 340-343 340Go-karting is a very popular recreational activity in the UK with easy access to race tracks throughout the country. However, due to the relatively high speeds and lack of seat belt restraint requirements, there are numerous injuries and a significant number of deaths world-wide each year.1 Small bowel injury as a result of any blunt abdominal trauma is rare (3.6%).2 Cases of isolated small bowel injury after blunt trauma are even less common (1%) with the majority (58-70%) associated with multiple injuries.2,3 Isolated duodenal injuries are extremely uncommon.We present three cases of isolated duodenal ruptures, of the D3/D4 segment, due to go-karting accidents occurring over a period of 5 months. Difficulties in clinical diagnosis of duodenal injury and the likelihood of significant complications 2,3 justifies maintaining a high index of suspicion with early investigation for patients attending with similar presentations. Case reports Case 1A healthy 29-year-old woman was brought to the accident and emergency department complaining of epigastric and right upper quadrant pain after crashing a go-kart into the side barriers of the track. Blunt abdominal trauma was sustained as the steering wheel impacted on her epigastrium during the crash. She was normotensive and had a pulse rate of 92 beats/min. There was tenderness in the right upper quadrant; however, the abdomen was soft and there was no guarding. Her white cell count (WCC) was raised at 26 × 10 9 cells/l and the haemoglobin (Hb) was normal at 12.1 g/dl. The amylase level was normal at 51 U/l. Chest and plain abdominal radiographs were unremarkable with no free air demonstrated.She was admitted and had an ultrasound scan of the abdomen the next day which demonstrated minimal perihepatic fluid (Fig. 1A) and normal solid organs. Blood investigations showed improvement and the WCC reduced to 12.1 × 10 9 cells/l. The patient remained stable with no worsening of her signs or symptoms. It was, therefore, decided to treat her conservatively and a computed tomography (CT) scan was performed to exclude any serious injury. This demonstrated a rupture in the wall of the early third part of duodenum, air pockets and a fluid collection in the retroperitoneal spaces (Fig. 1B), particularly in the retropancreatic and right anterior pararenal spaces. Some Imaging, Queen Elizabeth Hospital NHS Trust, London, UK ABSTRACT INTRODUCTION Isolated duodenal injury due to blunt abdominal trauma is extremely rare. We present a series of three such injuries due to go-karting accidents, which presented to our hospital over 5 months. CASE REPORTS Between October 2007 and February 2008, three cases of D3/D4 duodenal rupture presented to our hospital after go-karting accidents. Trauma occurred as a result of the steering wheel impacting on the abdomen. All patients presented similarly with symptoms of epigastric and right upper quadrant pain. In all cases, computed tomography scanning was highly suggestive of duodenal injury and, in particular, ...

Anastomotic and staple line leak following laparoscopic gastric bypass are recognised complications with significant mortality and morbidity. Several techniques have been described to reduce the incidence of staple line leaks, including reinforcement of staple lines using omental wraps, fibrin glue, and Peristrips and Seamguard. Using a similar principle, we describe a case report of the successful use of a Seamguard buttress in the repair of a staple line leak at the proximal gastric pouch following laparoscopic gastric bypass. The repair of the leak was confirmed by gastrogaffin contrast study as well as clinically as the patient progressed well in the postoperative period. Ten months following surgery, her weight had reduced from 125 kg (BMI 47.6 kg/m(2)) to 82.4 kg (BMI of 31.4 kg/m(2)). We suggest that surgeons facing similar problems may choose to employ this novel technique.