Background Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques. Methods In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281. Findings Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (< 5% for re-operation, re-admission, and implant loss, and < 10% for infection). Interpretation Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd.

AIM: To assess the rate of upgrade in our screening population to determine whether open excision biopsy of mucocoele-like lesions (MLL) is still required. MATERIALS AND METHODS: A retrospective review of the breast screening database from 1999-2014 was performed. RESULTS: MLL were identified on core biopsy in 113 women (0.6% of those recalled for a core biopsy). The majority (n = 100, 88%) had a localised cluster of calcification prompting screening recall. Eighty-seven percent (n = 99) underwent an excision biopsy; there was a 5% upgrade rate to malignancy (all low/intermediate ductal carcinoma in situ [DCIS]) and 15 women (15%) were found to have an additional "B3" lesion. Fourteen women did not undergo excision biopsy; none of these women had a subsequent cancer at an average of 5-years follow-up. Within the follow-up period, five additional cancers were identified, one of these was in the ipsilateral breast and location, albeit 9-years later. CONCLUSION: This is the largest study of MLL in the literature to date. The present findings show a 5% upgrade rate to DCIS. As long as the current management of low-risk DCIS remains surgical excision, the present results support continued excision of MLLs, either surgically or by vacuum-assisted biopsy. Crown Copyright (C) 2017 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. All rights reserved.

Aim: To assess and improve the quality of Secondary to Primary Care communication on discharge with a focus on post-surgical wound care. Background: Hospital discharge summaries are the principle means of relaying accurate information back to primary care healthcare providers regarding a patient's hospital attendance and any ongoing care that is required. The quality of these summaries can be quiet varied both nationally and local to our Trust. Subsequently the Surgical Directorate were seeing an increased level of additional emergency communication from Primary Care providers especially in relation to postoperative wound care. Methods: A survey was distributed to local Primary Care practitioners to assess satisfaction with the General Surgical Department wound care information located on the discharge summary. Using these results, a wound closure information document was developed and distributed to general practice surgeries, and a patient-held 'wound care' card was piloted for two months. The survey was then repeated to determine the success of the intervention. Findings: Post discharge communication was on the whole felt to be of poor quality and lacked a large amount of essential and desirable information. There was a particular absence of relevant information regarding surgical wound closure techniques utilised and their ongoing management. Many Primary Care practitioners acknowledge that their knowledge on this subject can be low. A Trust specific information leaflet combined with a dedicated patient held discharge information card can solve a number of these issues improving Primary and Secondary Care satisfaction and reducing the use of emergency resources and appointments.

Although rare in incidence, patients with neuroendocrine tumours (NET) live for many years and so have a high prevalence, and NETs frequently metastasise to the liver (NLM). Numerous treatment options have been implemented both for cure, and to implement disease control. Surgical treatment consists of curative resection, palliative cytoreductive resection and transplantation. Complete surgical resection is possible only in a subset of people with NLMs due to various factors. Ablative therapies may also be used, either as an adjunct to surgery or as a primary treatment. The purpose of the article is to summarise surgical treatment strategies in the management of patients with hepatic neuroendocrine metastases.

Neuroendocrine tumours (NET) frequently metastasise to the liver (NLM) and are associated with significant morbidity and mortality. Numerous treatment options have been implemented both for cure, and to implement disease control. Surgical treatment includes curative resection, palliative cytoreductive resection and transplantation. Complete surgical resection is only possible in a subset of people with NLMs due to excessive metastatic burden and anatomical location. Ablative therapies may be used either as an adjunct to surgery or as a primary treatment. The purpose of the following article is to summarise surgical treatment strategies in the management of patients with hepatic neuroendocrine metastases, based on the available literature.

Aim Mucosectomy by trans-anal endoscopic microsurgery (TEMS) allows safe and effective excision of benign rectal lesions. Preoperative endoscopic, clinical and ultrasonographic assessment aims to select benign lesions whilst avoiding inappropriate mucosectomy in lesions with malignancy. This study examines the relationship between lesion morphology and accurate benign preoperative classification of rectal lesions undergoing TEMS. Method Primary lesions preoperatively assessed as benign were identified from a prospective TEMS database. Operative specimen morphology was independently classified by two blinded investigators, using photographs, into flat-sessile, exophytic or mixed morphology. The accuracy of the preoperative assessment by rectal ultrasonography was compared with the results of histological examination of the excised specimen (?2 and Fishers exact tests). Results Of 167 lesions with adequate data, the morphological classification showed 60 flat-sessile, 56 mixed morphology and 51 exophytic tumours, of which 5, 7 and 9, respectively, contained unexpected malignancy (P = 0.48). Accurate preoperative assessment of a lesion as benign occurred in 89% of flat-sessile and mixed morphology (n = 55 and 49, respectively) and in 70% of exophytic lesions (n = 36) (P = 0.01). Only the exophytic group contained patients in whom preoperative endoscopic and ultrasonographic staging could not be confidently made (uTx). Histology demonstrated six of the seven uTx cases to be benign. Conclusion In this study exophytic polyps were less likely to be accurately classified as benign using preoperative ultrasonography/endoscopy when compared with flat-sessile or mixed morphology polyps.

An 82-year-old man underwent the routine removal of a common bile duct (CBD) stent by endoscopic retrograde cholangiopancreatography (ERCP). He had been fit and well prior to the procedure, and his past medical history was unremarkable. He had presented 18 months previously with acute cholangitis caused by gallstones.

Background: The British Society of Gastroenterology recommends that all patients with gallstone pancreatitis should undergo cholecystectomy,within 2 weeks. This study assessed whether these guidelines are feasible and cost-effective.Methods: Admissions for gallstone pancreatitis between January 2006 and January 2008 were reviewed. Readmissions for subsequent pancreatitis or biliary pathology were noted together with additional investigations, severity scores, hospital stay and time to cholecystectomy. The costs of readmission and theoretical costs of developing a dedicated operating list were provided by independent accountants.Results: During the 2 years, 153 patients were admitted. Twenty-one patients (13.7 percent) had further attacks requiring 40 readmissions. There were no deaths. Additional hospital costs related to readmissions were 172 pound 170, including bed occupancy (67 pound 860), investigations (12 pound 510) and 153 cholecystectomies on an existing theatre list (91 pound 800). The estimated cost of staffing a half-day theatre list every fortnight, performing 153 cholecystectomies, was 170 pound 391.Conclusion: Instigating a dedicated theatre for cholecystectomy after biliary pancreatitis has many potential benefits. The costs of readmissions and ad hoc operating are balanced by those of a dedicated theatre list in the long term. Implementation of the guidelines would save approximately 900 pound annually and be cost neutral.