Axillary Group Research Articles

Histomorphometric Study of Axillary Lymph Nodes in Different Age Groups

Abstract Background Although some age-related changes in lymph node histoarchitecture have been described, they are seldom taken into account in traditional depictions of lymph nodes. Recently introduced clinical procedures, such as intranodal vaccinations have demonstrated the need for an accurate knowledge of the degenerative processes of lymph nodes. It is thus deemed necessary to obtain a detailed insight into anatomical changes within the lymph node throughout life as age-related degeneration can have a strong impact on the outcome of these new therapeutic strategies. Aim To study the size and shape of the lymph nodes and to establish the age-dependent histoarchitectural changes in the lymph nodes in different age groups. Materials and Methods A cross-sectional study was conducted in a total of 35 axillary lymph nodes. The adult axillary group of lymph nodes were from subjects aged between 18 and 70 years. The fetal lymph nodes were collected from 8 stillborn fetuses between 37 and 42 weeks. Thickness of the cortex and diameter of the germinal centers were measured using ocular and stage micrometer. Results None of the fetal lymphocytic follicles showed evidence of a prominent germinal center. The germinal centers of young adults were not only more numerous but also larger in size when compared with the old. An age-related involution of the paracortical region was witnessed in the axillary lymph nodes. No evidence of lipomatous atrophy was encountered in any of the fetal lymph nodes. Interesting evidence of it was encountered in younger age groups. However, this was the most prominent feature in the older groups.

Endoscopic Axillary Approach Improves Patient Satisfaction of Gynecomastia Subcutaneous Mastectomy: A Cross-Sectional Study Using the BODY-Q Chest Module.

Gynecomastia is a common condition that refers to the benign enlargement of male breasts. Several minimally invasive techniques were invented to avoid visible scars in the chest area, but have limited effects on the dense fibroglandular breast tissue, and open excision remains the mainstay of treatment. Endoscopic subcutaneous mastectomy has the superiority of visualization, facilitating accurate dissection and hemostasis, also enabling inconspicuous scars. This study was designed to evaluate the patient-reported outcomes of the endoscopic axillary approach in treating gynecomastia, to interpret the differences between it and the conventional periareolar open excision method, and to present our experience utilizing this technique as a reliable alternative for Simon I and II gynecomastia. Eighty-three participants diagnosed with Simon I or II gynecomastia were included in this cross-sectional study, among which 31 were preoperative and 52 were postoperative patients. Postoperative participants were divided into two groups according to whether endoscopic axillary subcutaneous mastectomy (axillary group, n = 25) or periareolar open excision (periareolar group, n = 27) was performed. Patient-reported outcomes were assessed using the BODY-Q questionnaire, including the chest, nipples, body image, social, appearance-related distress, and scar domain, with scores ranging from 0 to 100. The BODY-Q score of both axillary and periareolar postoperative groups showed significant improvement on chest (p < 0.001), nipples (p < 0.001), body image (p < 0.001), and appearance-related distress (p < 0.005) scales, compared with the preoperative group. Of the scar scale, the axillary group rated higher scores than the periareolar group (p = 0.019), analysis of the individual scale items showed more positive responses in questions "Location of your scars?" (p < 0.001) and "How your scars look when they are not covered by clothes?" (p < 0.001), the item "Having to dress in a way to hide your scars?" also had a somewhat more positive responses from participants (p = 0.095). The present findings indicate that compared with the periareolar excision, patients who underwent gynecomastia subcutaneous mastectomy through endoscopic axillary approach have higher scar satisfaction with postoperative outcomes, this probably because of the well-hidden scar at the axilla, which leverages the psychologic burden of the patient after surgery. Future prospective studies are needed to measure changes over the entire patient journey, to find out the predictable factors of postoperative patient satisfaction, and determine how the objective outcomes relate to changes in patient's health-related quality of life. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Impact of the surgical modality for axillary lymph node dissection on postoperative drainage and seroma formation after total mastectomy

BackgroundThe most common complications after total mastectomy with axillary lymph node treatment are prolonged drainage and seroma formation. The aim of this study was to find factors correlated with prolonged fluid discharge (prolonged drainage or seroma formation after 20th operative day or later), including surgical techniques or devices and clinical factors.Patients and methodsA total of 202 conclusive primary breast cancer patients underwent total mastectomy with axillary lymph node treatment between January 7, 2014 and June 20, 2018 at our hospital. The factors that correlated with the total fluid discharge volume and prolonged fluid discharge were examined statistically. The surgical modalities for total mastectomy with axillary treatment were classified into the following three groups:, Group A; skin flap formation by EC and axillary lymph node dissection by EC with ligation of the arteries and veins, Group B; skin flap formation by EC and axillary lymph node dissection by ultrasonic dissector (UD) without ligation of the vessels. Group D; skin flap formation by electrocautery (EC) and axillary lymph node dissection by picking up using forceps and ligation (PL).ResultsThe total fluid discharge volume and prolonged fluid discharge after total mastectomy with sentinel node retrieval (33 patients) were significantly lower than those after total mastectomy with axillary lymph node dissection (169 patients). In patients treated without drainage, a high rate of seroma formation and prolonged fluid discharge were observed, and 1 patient developed seroma infection.In the total mastectomy with axillary lymph node dissection group, logistic regression analysis revealed that body mass index, 1-week drainage volume, and surgical modality were independently correlated with prolonged fluid discharge.ConclusionsThe surgical procedure for axillary lymph node dissection should be considered to avoid prolonged fluid discharge, and the lymph vessels should be ligated in axillary lymph node dissection. An ultrasonic dissector was not effective in reducing the total fluid discharge volume. An optimal axillary lymph node dissection technique should be developed. For the patients without drainage, careful postoperative treatment should be given to avoid infectious seroma formation, even for patients who underwent total mastectomy with sentinel lymph node retrieval.

Transcranial Doppler is an effective method in assessing cerebral blood flow patterns during peripheral venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF. Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes. The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits. TCD appears to be an effective tool for indirect monitoring of CBF in patients withECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF.

Axillary artery cannulation reduces early embolic stroke and mortality after open arch repair with circulatory arrest

ObjectiveTo evaluate the efficacy of axillary artery cannulation for early embolic stroke and operative mortality, we retrospectively compared the outcomes between patients with or without axillary artery cannulation during open aortic arch repair with circulatory arrest. MethodsBetween January 2004 and December 2017, 468 patients underwent open aortic arch repair with circulatory arrest using antegrade cerebral perfusion and were divided into 2 groups according to the site of arterial cannulation: the axillary artery (axillary group, n = 352) or another site (nonaxillary group, n = 116) groups. Embolic stroke was defined as a physician-diagnosed new postoperative neurologic deficit lasting more than 72 hours, generally confirmed by computed tomography or magnetic resonance imaging. ResultsAfter propensity score matching, the patients' characteristics were comparable between the groups (n = 116 in each). The incidences of acute type A dissection, aortic rupture, shock, or emergency operation were similar between groups. The incidence of early embolic stroke was significantly lower in axillary group (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046). Also, 30-day mortality (n = 3 [2.6%] vs n = 10 [8.6%]; P = .046) and in-hospital mortality (n = 3 [2.6%] vs n = 11 [9.5%]; P = .027) occurred significantly lower in the axillary group. ConclusionsAxillary artery cannulation reduced the early embolic stroke and early mortality after open arch repair with circulatory arrest. Axillary artery cannulation as the arterial cannulation site during open arch repair with circulatory arrest may be helpful in preventing embolic stroke and reducing early mortality.

Study of cytomorphological spectrum of tuberculous lymphadenitis and correlation with AFB positivity

A prospective study of lymph node FNAC was done in 500 cases presenting with tuberculous lymphadenitis over a duration of 6 months. Most of the patients were in the age group of 21-40 years, with female to male ratio of 1.9:1. Lymph node enlargement was noted in all the cases, wherein the lymph nodes were multiple, soft to firm and matted in 152 cases (30.4%) and single and discrete in 348 cases (69.6%). The most common group involved was the cervical group of lymph nodes (87.2%), followed by the axillary group (9.4%). Most cases showed whitish aspirates (56%). 21% cases showed cheesy appearance of aspirates. Associated history of contact was found in 97 cases (19.4%). 142 cases (28.4%) had past history of tuberculosis, out of which 52 cases had completed antitubercular treatment (ATT) for 9 months, while 42 cases were defaulters who had not completed ATT course. Epithelioid granuloma with necrosis (63.6%) pattern was the most common followed by epithelioid granuloma without necrosis (22.4%). 9 HIV seropositive cases (1.8%) were seen, out of which, epithelioid granuloma with necrosis and only caseous necrosis were seen in 3 cases (33.33%) each. AFB positive cases were 36%. Necrotizing lymphadenitis showed maximum AFB positivity (95.55%), which was followed by necrotizing and suppurative lymphadenitis which showed 92% AFB positivity. We did not encounter any complications during and after aspiration procedure. Keywords: Cytomorphological pattern, Tuberculous lymphadenitis, FNAC, AFB positivity.

Abstract OT2-02-01: A confirmation study of omitting axillary dissection in patients with breast cancer and positive sentinel nodes

Abstract Background The omission of axillary dissection for positive sentinel-node breast cancer is considered the standard treatment for patients who undergo breast conserving surgery and radiation therapy, according to the results of ACOSOG-Z0011 and AMAROS trials. On the other hand, some surgeons still think that the surgical stress of axillary dissection is minimal, and dissection is permitted. Furthermore, Z0011 contains several problems, such as insufficient number of entry cases and lack of radiation field unity. Thus, we planned a prospective trial to confirm the safety of omitting axillary dissection in patients with breast cancer and positive sentinel nodes. Trial design This is a single arm, confirmation study of three medical centers. Prior to surgery, informed consent is obtained, and patients are registered primarily. After surgery, patients with 1 to 2 positive sentinel nodes, for whom axillary dissection was omitted, are finally included in this trial at final registration. Eligibility criteria Patients with histologically-diagnosed breast cancer, Tis–2, N0 based on a core needle biopsy, will be included in this trial. Eligible patients must be between 20 and 80 years of age, with a performance status of 0–2 and adequate organ function. They must not have undergone any prior operation, radiation therapy, chemotherapy, endocrine therapy, or immunotherapy. Specific aims The primary endpoint is 5-year (y) axillary recurrence rate. Secondary endpoints are 5-y overall survival, 5-y recurrence-free survival, 5-y local recurrence-free survival, the rate of upper-limb lymphedema, quality of life, and comparison of axillary recurrence rates between patients with two or more dissected nodes and those with only one positive node. Statistical methods The expected rate of axillary recurrence is 2.0%, and non-inferiority is defined as an axillary recurrence lesser than or equal to 5% in the axillary radiotherapy group. The sample size was calculated with a study power of 80% and type I error of 10% (two-sided). The required number of patients is estimated to be 189. Present and target accrual Patient accrual from the three medical centers was initiated in July 2016. We plan to enroll a total of 189 patients at final registration in this trial. Citation Format: Jibiki N, Hirano A, Ochi T, Sakamoto A, Horiuchi K, Noguchi E, Omi Y, Ogura K, Inoue H, Kamio T, Naritaka Y, Fujibayashi M, Hiroshima K, Nagashima Y, Sakai S, Karasawa K, Okamoto T. A confirmation study of omitting axillary dissection in patients with breast cancer and positive sentinel nodes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-02-01.

Innominate vs. Axillary Artery Cannulation in Aortic Surgery: a Systematic Review and Meta-Analysis.

ObjectiveTo investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery.MethodsA comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017.ResultsOnly three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups.ConclusionThere is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.

Outcome after aortic, axillary, or femoral cannulation for acute type A aortic dissection

ObjectiveThe optimal method for arterial cannulation in acute aortic dissection type A (ADA) remains controversial. The aim of this study was to compare central ascending aortic, axillary, and femoral cannulation in patients who underwent surgery for acute ADA. MethodsBetween 2006 and 2017, 584 patients were operated on for acute ADA. Of those, 355 (61%) underwent ascending aortic, 101 (17%) right axillary, and 128 (22%) femoral cannulation for arterial inflow. Clinical features and outcomes were compared after inverse probability weighting. ResultsAfter inverse probability weighting there were no statistical differences in preoperative characteristics. Operative details differed significantly among the 3 groups: hemiarch replacement was performed more often in the central aortic and the femoral group (P < .001), whereas total arch replacement was performed more often in the axillary group (P < .001). Cardiopulmonary bypass (P = .022) and aortic cross-clamp (P = .021) times were shortest in the aortic cannulation group and longest in the femoral cannulation group. Postoperative morbidities were similar; procedure-related stroke (P = .783) and the need for renal replacement therapy (P = .446). In-hospital mortality (P = .680) and long-term survival were similar (log rank, P = .704). Multilevel multivariate mixed effect logistic regression showed that the cannulation strategy was not associated with in-hospital mortality. ConclusionsCentral ascending aortic cannulation in patients with ADA can be used as safely as axillary or femoral cannulation, providing another option for quick and easy establishment of cardiopulmonary bypass.

Cosmetic outcomes and quality of life in children with cardiac implantable electronic devices.

Axillary implant location is an alternative implant location in patients for cardiac implantable electronic devices (CIEDs) for the purposes of improved cosmetic outcome. The impact from the patient's perspective is unknown. The purpose of this study was to compare scar perception scores and quality of life (QOL) in pediatric patients with axillary CIED implant location versus the standard infraclavicular approach. This is a multicenter prospective study conducted at eight pediatric centers and it includes patients aged from 8 to 18years with a CIED. Patients with prior sternotomy were excluded. Scar perception and QOL outcomes were compared between the infraclavicular and axillary implant locations. A total of 141 patients (83 implantable cardioverter defibrillator [ICD]/58 pacemakers) were included, 55 with an axillary device and 86 with an infraclavicular device. Patients with an ICD in the axillary position had better perception of scar appearance and consciousness. Patients in the axillary group reported, on average, a total Pediatric QOL Inventory score that was 6 (1, 11) units higher than the infraclavicular group, after adjusting for sex and race (P=0.02). QOL is significantly improved in axillary in comparison to the infraclavicular CIED position, regardless of device type. Scar perception is improved in patients with ICD in the axillary position.

OC03 AXILLARY VERSUS FEMORAL ARTERY CANNULATION IN AORTIC ARCH SURGERY: A SINGLE CCENTRE EXPERIENCE

Background and Aim: The best strategy of arterial cannulation during aortic arch replacement is still debated. We reported our experience with the Axillary and Femoral artery cannulation, comparing the incidence of major neurological events and in-hospital mortality. Methods: Between 1996 and 2016, 938 consecutive patients (pts) underwent arch replacement in our center. We included only two groups of patients, according to the type of arterial cannulation: Axillary group with 282 pts and Femoral group with 409 pts. Baseline characteristics of the patients are reported in Table 1. Results: The hemiarch replacement was performed more often in Femoral group (57.2% vs 38.3%, p = .001). The Femoral cannulation was the most commonly used in urgent/emergent cases (56% vs 36.9%, p = .001). Cardiopulmonary bypass time (Axillary: 216.08 ± 61.47 vs Femoral: 203.78 ± 63.69; p = .001), Cross-Clamp Time (141.12 ± 47.5 vs 132.71 ± 49.10; p = .016), Circulatory Arrest Time (2.51 ± 1.74 vs 4.26 ± 2.49; p = .001) and antegrade selective cerebral perfusion time (69.19 ± 34.46 vs 58.84 ± 34.94; p = .001) were longer in Axillary group. Hospital mortality was similar between the two groups (12.1% vs 13.9%, p = .546) as well as for permanent neurological deficit (6.7% vs 7.3%, p = .881). Transient neurological deficit is significantly higher in the Axillary group (17.4% vs 11.0%, p = .022). Conclusions: Our study confirms that Axillary and Femoral artery cannulations were associated with similar outcomes after aortic arch surgery. The Axillary cannulation was used more frequently in complex repair of the aortic arch, while the Femoral can be still considered a viable option, especially in urgent/emergent cases.

The ultrasound-guided selective nerve block in the upper arm: an approach of retaining the motor function in elbow

BackgroundProximal brachial plexus blocks can lead to an extended period of motor paralysis and delay the return of motor function. This could influence patient satisfaction, and extend hospitalizations. The aim of the study is to compare a selective distal nerve block of the arm to a proximal axillary block, both ultrasound-guided, in terms of their motor block intensity of the elbow. Our hypothesis is that a selective nerve block of the arm would result in a different motor block of the elbow, compared to the axillary block.MethodsA sample size of 24 patients who were undergoing elective surgery (ASA I-III) of the wrist, hand or forearm was randomly divided into two groups: Arm Group (n = 12) and Axillary Group (n = 12). The Arm Group received ultrasound-guided block of the median, ulnar, and medial antebrachial cutaneous nerves at the level of upper-median 1/3 of the arm, and a block of the radial and musculocutaneous nerves at the level of low-median 1/3 of the arm, while the Axillary Group received ultrasound-guided axillary brachial plexus blocks. Both blocks used in combination with general anesthesia.ResultsOur results demonstrated that the incidence of motor block at the elbow in the Arm Group was lower than in the Axillary Group. Compared with the Axillary Group, the duration of motor block at the elbow and the onset time of sensory block in the Arm Group were shortened. The patient satisfaction was increased in the Arm Group. There were no differences in the duration of the sensory block, the effect on postoperative analgesia, or in the duration of the motor block at the shoulder between both groups.ConclusionOur study showed that ultrasound-guided selective nerve block in the upper arm allowed improved retention of motor function at the elbow compared to axillary block. Secondarily, the ultrasound-guided selective nerve block seemed to provide similar analgesia after surgery of the hand or forearm with an enhanced patient satisfaction.Trial registrationChinese Clinical Trial Registry, ChiCTR-IOR-16008769. Registered 3 July 2016.

Innominate Versus Axillary Artery Cannulation for the Hemiarch Repair

BackgroundInnominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing selective antegrade cerebral perfusion during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide less resistance to high flow during bypass and selective antegrade cerebral perfusion. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss. MethodsThis was a single-center retrospective analysis of 206 patients who underwent hemiarch replacement between 2009 and 2017. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary and innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp time, circulatory arrest (CA) time, postoperative transfusions, intensive care unit length of stay, development of any neurological complications, end-organ failure, and mortality. Subgroup analysis was performed for elective and emergent cases. ResultsAxillary and innominate artery cannulation accounted for 37% (n = 77) and 67% (n = 129) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of renal disease in the axillary group (16% versus 6%, P = 0.05). More emergent cases were performed in the axillary group (61% versus 17%, P < 0.001). Innominate cases had shorter CPB times (189 versus 150 min, P < 0.001) and CA (22.5 versus 11 min, P < 0.001) times overall. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference in operative times. Less transfusions were given in the innominate group including units of red blood cells (2 [0-6] versus 0 [0-2], P < 0.001), units of platelets (2 [1-3] versus 1 [0-2], P = 0.001), and units of plasma (6 [2-9] versus 2 [0-4], P < 0.001). A similar trend was observed in the elective subgroup. No difference in transfusions was observed in the emergent subgroup. There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups. ConclusionsAlternate cannulation strategies for open arch anastomoses are evolving with a trend toward using the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.

Time to redefine the intramammary lymph node as a separate entity?

The lymphatic drainage for the majority of primary breast tumors is to the axillary lymph nodes (ALNs). Some, however, drain to the so-called extra-axillary basins, namely the internal mammary, supra- and infraclavicular regions. Another potential drainage route includes the intramammary lymph nodes (IMLNs). Current guidance suggests IMLNs should be considered as part of the axillary group, potentially affecting axillary management. However, due to evolution in imaging and advancement in technology, IMLNs may now be distinguished more accurately pre-operatively. There are currently no published guidelines for the management of IMLNs in the United Kingdom. The authors suggest that it is time to reclassify IMLNs as a separate focus of cancer and treat it as a separate entity. Clin. Anat. 31:684-687, 2018. © 2018 Wiley Periodicals, Inc.

Cannulation of innominate artery as an alternative to axillary artery in repair for type A aortic dissection

BackgroundThe aim of this study was to compare innmoinate artery cannulation with axillary artery cannulation in the setting of repair of acute type A aortic dissection. The primary end point of this study was the difference in neurological complications. The difference in mortality, operative time and limb complications were the secondary end points. MethodsBetween January 2014 and January 2016, 30 patients operated upon in Kasr Al-Aini hospitals, Egypt were studied prospectively. All patients underwent repair of ascending aorta ± aortic arch for type A aortic dissection using open clamp technique and antegrade cerebral perfusion. Patients with dissected innominate artery were excluded from this study. Patients were divided randomly into two equal groups. Patients with axillary cannulation were allocated to group A, while patients with innominate artery cannulation were allocated to group B. ResultsBentall operation was done in 6 patients in group A (40%) and 8 patients in group B (53.3%). Tirone David operation was done in 9 patients in group A (60%) and 7 patients in group B (46.6%). The Ischemic time was 147.3 ± 35.1 min in group A versus 138.3 ± 51.9 min in group B with no statistical significance. The operative time was obviously shorter (313.6 ± 23.48min) in the innominate artery group versus 348.3 ± 29.25 min in the axillary artery group with no statistical significance. One patient died in each group. One patient in group A had a transient cognitive dysfunction versus two patients in each group B. One patient in group A had a stroke. Two patients (13.3%) of the axillary group had a temporary upper limb parasthesia that resolved completely in 3 months. One patient (6.6%) in the same group had a superficial wound infection. No adverse events were reported with innominate artery grafting. ConclusionsInnominate artery cannulation shortened the operative time and reduced complications related to the cannulation site as compared to axillary artery cannulation. It provided a safe alternative for antegrade cerebral perfusion as regards the incidence of neurological complications.

Quality of Life After Sentinel Lymph Node Biopsy Versus Complete Axillary Lymph Node Dissection in Early Breast Cancer: A 3-Year Follow-up Study

The rating of life quality may belong to the method of surgical treatment: after the axillary lymph node dissection patients may suffer from arm symptoms; after sentinel lymph node biopsy women may highlight the anxiety about the success of radical treatment. The aim was to assess the influence of sentinel lymph node biopsy on the quality of life of the patients with early stage breast cancer compared with total axillary lymph node dissection. In a prospective case-control study, 48 patients with early invasive breast cancer and no evidence of lymph nodes involvement underwent breast conserving surgery with sentinel lymph node biopsy. They were grouped as matched pairs with the patients who underwert axillary lymph node dissection, according to the age, TNM stage, localization, hormonal receptor status, and surgical characteristics. Quality of life was evaluated using the QLQ-C30 and QLQ-BR-23 questionnaires before surgery and after 1, 3, 6, 12, and 36 months. The patients who underwent sentinel lymph node biopsy scored better on the emotional functioning, pain, sexual functioning, and future perspective scales in comparison with those who underwent axillary lymph node dissection. The score on the arm symptom scale remained significantly better in the sentinel lymph node biopsy group than the axillary lymph node dissection group within the overall follow-up period. The women who underwent sentinel lymph node biopsy experienced better quality of life than the patients who underwent axillary lymph node dissection.

Femoral artery versus right axillary artery cannulation in various cardiac procedures, a single center experience: The quest for the holy grail

BackgroundThere are many arterial cannulation sites to establish cardiopulmonary bypass (CPB). Each site has its advantages and disadvantages. Organ malperfusion especially the cerebral malperfusion during CPB is the most critical outcome in comparing different arterial sites. We aimed to evaluate safety and efficacy of axillary and femoral arterial cannulation in various situations. MethodsThis retrospective observational study, included 75 patients underwent redo valve surgery or denovo thoracic aorta surgery. Patients were reviewed in terms of organ malperfusion namely brain and kidney; and cannulation site related complications. Patients were divided into two groups Femoral group (n = 46) and Axillary group (n = 29). ResultsThe mortality in the femoral group was 4.35%, while the axillary group showed a 3.45% mortality; without statistically significant difference. The axillary group had a significantly lower total hospital stay (p value 0.002), and highly significant lower ventilation hours (p value < 0.001). Other post-operative complications were lower in the axillary groups, without reaching statistical significance. ConclusionsBoth axillary and femoral artery cannulation provide a safe quick route for establishing CBP support in critical conditions before opening the chest. The axillary route is more technically demanding while the femoral route is handier in such cases. Individual arterial cannulation strategy should be done for each patient with a backup plan.

Lymph drainage of the upper limb and mammary region to the axilla: anatomical study in stillborns.

We studied the lymphatic drainage of the upper limb and mammary region directing to the axilla to investigate whether independent pathways can be observed or whether anastomoses and shared drainage occur between them. This analysis aimed to assess the safety of axillary reverse mapping (ARM) in breast cancer treatment and to understand the development of lymphedema after sentinel lymph node biopsy (SLNB) alone. Seven unfixed stillborn fetuses were injected with a modified Gerota mass in the peri-areolar area, palm and dorsum of the hands, formalin fixed, and then submerged in 10% hydrogen peroxide solution. Microsurgical dissection was then performed on the subcutaneous cellular tissue of the upper limb, axillary region, and anterior thorax to expose the lymphatic vessels and lymph nodes. The dye injected into the upper limb reached either the lateral axillary group, known to be exclusively responsible for upper limb drainage, or the anterior group, which is typically related to breast drainage. There was great proximity among the pathways and lymph nodes. Communicating lymphatic vessels among these groups of lymph nodes were also found in all studied cases. Lymphedema remains a challenging morbidity in breast cancer treatment. ARM and SLNB aim to avoid unnecessary damage to the lymphatic drainage of the upper limb. However, our anatomical study suggests that ARM may have potential oncological risks because preserved lymph nodes may harbor malignant cells due their proximity, overlapping drainage pathways, and connecting lymph vessels among lymph nodes.

Real-time ultrasound-guided axillary vein cannulation in children: a randomised controlled trial.

The axillary vein is a good site for ultrasound-guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real-time ultrasound-guided axillary vein cannulation with conventional infraclavicular landmark-guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound-guided axillary vein (axillary group) or landmark-guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first-attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25-6.48, p=0.010). The first-attempt success rate was 46% for the axillary group and 40% for the landmark group (p=0.274) and median time to cannulation was 156s for the axillary group and 180s for the landmark group (p=0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p=0.08). We conclude that axillary vein cannulation using a real-time ultrasound-guided in-plane technique is useful and effective in paediatric patients.

Comparison of the anesthetic effect of ultrasound-guided brachial plexus block by different approaches in distal radius surgery

Objective To compare the anaesthetic effect of ultrasound-guided brachial plexus block by different approaches (interscalene, axillary, supraclavicular) in distal radius surgery. Methods Ninety adult patients undergoing elective surgery for distal radius fracture open reduction and internal fixation, distal radius fracture after implant removal surgery distal radius fracture, were randomly divided into interscalene group(group A), axillary group(group B) and supraclavicular group (group C) for brachial plexus block under ultrasound-guided(n=30). The performance time and complications were recorded. Besides, the onset time and block execution time of median nerve, ulnar nerve, radial nerve, lateral medial cutaneous nerve, forearm medial cutaneous nerve were evaluated. Results There is no significant difference in performance time(P>0.05) and the onset time of pain block in median nerve, radial nerve, lateral medial cutaneous nerve (P>0.05). As for ulnar nerve and medial antebrachial cutaneous nerve, there were no difference in onset time of pain block between group A[(21±6) min] and group C[(20±5) min] (P>0.05), but they were longer than group B[(8±5) min] (P 0.05), but they were longer than group B[(10±6) min] (P<0.05). The complete suceess rate of group B(90%) were higher than other two groups. We found that two patients in group A and one patient in group C were complicated with phrenic nerve block and one patient in group B showed little tolerance of tourniquet. Conclusions Ultrasound-guided axillary brachial plexus block in the distal radius surgery is recommended because of better blockage of ulnar nerve and medial antebrachial cutaneous nerve and fewer complications. Key words: Ultrasound; Brachial plexus block; Distal radius