Metal Clips Research Articles

A Metal Detector for Clip Location Tracking of Stomach and Colon Cancer during Laparoscopic Surgery

In laparoscopic surgery for colorectal and gastric cancer, it is difficult to locate the tumor in the cavity for excision. Tumors in the colon or stomach are blocked by mucous membranes; thus, the view from the cavity is obscured. Therefore, to determine the location of the tumor, a marker can be installed around the tumor and the location of the tumor can be found using a sensor. Until now, most of the clip-detectors that have been developed can detect the location of tumors for either colorectal or gastric cancer. The research on the development of a detector that can detect the location of tumors for both colorectal and gastric cancer, is insufficient. Most detectors for tumor location determination are devised using a magnet by connecting a wire to a clip. In this method, the position of the magnet moves along the length of the wire. Therefore, it is difficult for the detector to detect the exact location of the tumor. Based on this method, this study designs a clip maker to determine the location of a tumor and a detector that can detect the clip. The clip and the sensing element are directly connected. The clip is developed using ferrite and coil to generate a magnetic field induced by an eddy current in the metal (clip), and the detector is designed using the Colpitts oscillator to induce a magnetic field. After installing the prepared clip at the tumor location, the detector is used to detect the clip, and accordingly, the location of the tumor can be identified using the detector. To test the performance of the clip and detector, we conducted animal experiments. In the course of the animal experiment, four clips were installed in the colon and stomach, and we succeeded in detecting all the clips. Because the clip-detector is used to locate the tumor during laparoscopic surgery, an endoscope must be used. Therefore, it is predicted that the demand for laparoscopic surgery and endoscopic medical industry will increase because of the clip-detector.

Ovarian transposition in order to preserve fertility before irradiation in a young patient with cervical cancer

Ovarian transposition has been imagined for young women diagnosed with pelvic malignancies who are submitted to surgery, who are further candidates for irradiation and who deserve fertility preservation. The most commonly indication for this procedure are represented by rectal and hematological malignancies; in certain cases diagnosed with gynecological malignancies in early stages such as cervical cancer ovarian preservation can be also taken in consideration in order to preserve fertility; however, ovarian transposition should be taken in consideration in order to remove the ovaries from the radiation field. The aim of the current paper is to report the case of a 31 year old patient diagnosed with a stage IIA cervical cancer in whom a total radical hysterectomy en bloc with right adnexectomy and pelvic lymph node dissection was performed; meanwhile the left ovary was transposed at the level of the left lumbar area, 2 cm above the left iliac crest and metallic clips were placed at the inferior margins in order to be easily identified when performing adjuvant radiation therapy.

Cross Facial Nerve Grafting for Smile Restoration: Thoughts on Improving Graft Inset.

Summary:Cross facial nerve grafts (CFNGs) are one of the most ubiquitous and time-honored surgical tools used in facial reanimation. They may be used for targeting different mimetic muscles in the subacute setting as well as to innervate newly placed muscle flaps in varied facial subunits. In our experience, when used specifically for smile reanimation in two-stage strategies with either traditional “babysitting” approaches in nerve transfers or free functional muscle transfers, the second stage may present some challenges in CFNG identification as well as injury to the previously banked nerve graft. We present some technical modifications in the first-stage CFNG inset that can make the second stage easier and safer. These modifications include: (1) marking the course of the nerve graft with surgical metal clips and inserting loose circumferential sutures throughout the distal course of the nerve in the recipient area to avoid displacement; (2) transferring the nerve graft through the nasal sills rather than lips, protecting it from damage during insertion of free functional muscle transfer; and (3) routing the nerve from the lateral nose to the preauricular area over the zygomatic arch, allowing easier dissection and banking of adequate graft length to provide tension-free coaptation with the flexibility of nerve coaptation in variable positions.

Bile leakage and the number of metal clips on the cystic duct during laparoscopic cholecystectomy.

The most common way of closing the cystic duct in laparoscopic cholecystectomy is by using metal clips (>80%). Nevertheless, bile leakage occurs in 0.4%-2.0% of cases, and thus causes significant morbidity. However, the optimal number of clips needed to avoid bile leakage has not been determined. The primary aim of this study was to evaluate bile leakage and post-procedural adverse events after laparoscopic cholecystectomy concerning whether two or three clips were used to seal the cystic duct. Using a retrospective observational design, we gathered data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (ERCP) (GallRiks). From 2006 until 2019, 124,818 patients were eligible for inclusion. These were nested to cohorts of 75,322 (60.3%) for uncomplicated gallstone disease and 49,496 (39.7%) with complicated gallstone disease. The cohorts were grouped by the number (i.e. two or three) of metal clips applied to the proximal cystic duct. The main outcome was 30-day bile leakage and post-procedural adverse events. No significant differences surfaced in the rate of bile leakage (0.8% vs 0.8%; P = .87) or post-procedural adverse events (three clips, 5.7% vs two clips, 5.4%; P = .16) for uncomplicated gallstone disease. However, for complicated disease, bile leakage (1.4% vs 1.0%; P < .001) and post-procedural adverse events (10.2% vs 8.6%; P < .001) significantly increased when the cystic duct was sealed with three clips compared with two. Because no differences in the rates of bile leakage or adverse events emerged in uncomplicated gallstone disease when a third clip was applied, a third clip for additional safety is not recommended in such cases. On the contrary, bile leakage and adverse events increased when a third clip was used in patients with complicated gallstone disease. This finding probably indicates a more difficult cholecystectomy rather than being caused by the third clip itself.

Importance of biopsy site selection for peritoneal regression grading score (PRGS) in peritoneal metastasis treated with repeated pressurized intraperitoneal aerosol chemotherapy (PIPAC).

ObjectivesThe four-tiered peritoneal regression grading score (PRGS) is used for histological response evaluation in patients with peritoneal metastasis (PM) treated with pressurized intraperitoneal aerosol chemotherapy (PIPAC). Four quadrant biopsies (QBs) from the parietal peritoneum should be assessed by PRGS, but consensus on biopsy site strategy for follow-up biopsies during repeated PIPACs is lacking. We aimed to evaluate whether there is a difference between PRGS in QBs from clips marked PM (QB-CM) compared to biopsies from PM with the visually most malignant features (worst biopsy, WB).MethodsProspective, descriptive study. During the first PIPAC, index QBs sites were marked with metal clips. During the second PIPAC, an independent surgical oncologist selected biopsy site for WB and biopsies were taken from QB-CM and WB. One blinded pathologist evaluated all biopsies according to PRGS. From each biopsy, three step sections were stained H&E, followed by an immunostained section, and another three step sections stained H&E.ResultsThirty-four patients were included from March 2020 to May 2021. Median age 64 years. Maximum mean PRGS in QB-CM at PIPAC 1 was 3.3 (SD 1.2). Maximum mean PRGS in QB-CM at PIPAC 2 was 2.6 (SD 1.2), whereas mean PRGS in WB at PIPAC 2 was 2.4 (SD 1.3). At PIPAC 2, there was agreement between maximum PRGS from QB-CM and PRGS from WB in 21 patients. Maximum PRGS from QB-CM was higher in nine and lower in four patients, compared to PRGS from WB.ConclusionsBiopsies from QB-CM did not overestimate treatment response compared to biopsies from WB.

Comparison of wound closure techniques after thyroid and parathyroid surgery: an updated systematic review and network meta-analysis.

We designed and conducted the present study to evaluate the optimal wound closure technique after thyroid and parathyroid surgery in terms of perioperative safety, efficacy, and cosmetic outcomes. A systematic literature review and network meta-analysis (NMA) was performed according to the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Literature screening was completed at 10/12/2021. A random effects multivariate network meta-analysis under a frequentist framework was implemented. Statistical significance was considered at the level of p < 0.05. Overall, 18 studies and 1314 patients were included. Conventional sutures (CS) received the best ranking (SUCRA: 90.1%) in wound-related morbidity. Metal clips (MC) was the best option for reducing the overall operation (SUCRA: 99%) and wound closure (SUCRA: 72.3%) duration. Moreover, adhesive strips (AS) had the higher probability of minimizing postoperative pain during the 2nd and 3rd postoperative days. Subcuticular suture (SS) was the most probable method for achieving optimal, long-term, patient-assessed, and surgeon-assessed cosmesis. However, MC had the highest mid and long term, independent-assessed, scar ranking (SUCRA 80.5% and 62.9%). Based on the inconclusive results and the several study limitations, further large-scale RCTs are required.

Development and validation of a novel porcine bile duct dilation model for EUS training.

Background and study aims Image-guided minimally invasive techniques have transformed the management of malignant and benign bile duct obstructions. These evolving techniques are being widely adopted and applied and hands-on training using high quality models is required to improve the proficiency of practitioners. This experimental study aimed to validate an in vivo porcine model created to simulate bile duct dilation for interventional endoscopic ultrasound (EUS) hands-on training curriculums. Materials and methods Thirty-six porcine models were involved and the procedures were performed in an experimental hybrid operating room under general anesthesia. Animals underwent endoscopic duodenal papilla clipping with several hemostatic metallic clips. After a survival period of 24 to 48 hours, the models with effective intrahepatic and extrahepatic bile duct dilatation were included in the hands-on training. Trainees and faculty were given structured evaluations of the model realism and usefulness. Results Extrahepatic bile duct and gallbladder dilation was achieved in all 36 of the models, and in 11 of the 36 models, a treatable intrahepatic duct dilatation was achieved. During the hands-on training, EUS-guided biliary drainage, EUS-guided transgastric gallbladder drainage, and EUS through-the-needle microbiopsy forceps procedures were feasible. Overall, 75 % of the experts and trainees evaluated the training as excellent. Conclusions We present a minimally invasive, reliable and time- effective model of extrahepatic dilation suitable for interventions. The model was less effective for intrahepatic ducts, which should be considered if intrahepatic biliary dilation is required for training.

Laparoscopic control of postoperative bleeding from the inferior vena cava due to the focal failure of vascular stapling induced by a small metal clip after laparoscopic living donor right hepatectomy

Laparoscopic control of postoperative bleeding from the inferior vena cava due to the focal failure of vascular stapling induced by a small metal clip after laparoscopic living donor right hepatectomy

Robotized cell design for part assembly in the automotive industry

Today, the automotive industry faces its biggest challenge, which is keeping a constant evolution, accounting for the market needs in what comes to the enormous quantity of parts and systems that go hand in hand with the production of the vehicle, and at the same time, keep up with the quality requirements and deadlines. Throughout time, automation and robotics became the best way to achieve the goals required by the market. In the automotive industry, automation presents itself at a continuous evolution, constantly presenting new solutions, and the production and assembly lines increasingly resort to completely automated processes. This work is based on the needs of an automotive parts’ supplier. In which regards to the injection of plastic, the production is fluent and quick, and to take advantage of such production speed, it is desirable to execute the assembly steps immediately after the removal of the parts from the injection moulds. The proposed work consists of the design of a robotized cell with the goal of inserting metal clips in two different automotive parts after the injection process. The idea is to conceptualize and conceive a completely automated equipment, capable of executing this task using a six-axis robot. To secure the part for clip assembly, the equipment must be ready to ensure the positioning and locking of the part in all axes and, to lighten the robot’s job, it must also be capable of using a feeding system to load the robot’s tool. The results of this project were positive, the equipment was successfully concluded and delivered to the customer, meeting the construction requirements, and, most importantly, the cycle time.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Underlying mechanisms of saphenous vein graft stenosis after coronary artery bypass caused by clipping of the side branches: an experimental study.

BackgroundSaphenous veins are regular bypass conduits selected in non-left anterior descending artery (LAD) coronary artery bypass graft (CABG) surgery. Despite the technical errors, acute thrombosis, intimal hyperplasia and arteriosclerosis which could lead to saphenous vein graft (SVG) failure, the metal-clipping-related SVG failure is unique and rare. This study was conducted to investigate the clinical and underlying mechanisms of the metal-clipping-related SVG failure.MethodsWe collected 6 typical cases of the metal-clipping-related SVG failure in 41 patients who were diagnosed graft stenosis by coronary angiograph after CABG in the Department of Cardiology, Beijing Anzhen Hospital, from January 2020 to September 2021. Furthermore, we built an in vitro model to verify the identical intravascular ultrasound (IVUS) pattern of metal clip.ResultsThere were 6 in 41 cases of SVG stenosis caused by clipping of the side branches. We found that the stenosis of SVG caused by metal clipping mostly occurred at the corner and multipole clipping points. In this situation, great resistance could be felt when pushing the instruments through the stenosis and crystallized cholesterol was rarely caught by the distal protection device. We verified the similar IVUS pattern of metal clip at the side-branches of SVG in vitro.ConclusionsThe metal-clipping-related stenosis may lead to SVG failure. The stenosis of SVG caused by metal clipping mostly occurred at the corner and multipole clipping points. IVUS showed great modality for clarification.

Assessment of low-cost surgical metallic clip placement for tumor localization in BIRDAS VI breast cancer patients undergoing neoadjuvant chemotherapy

BackgroundNeoadjunvant chemotherapy has become a challenging connotation for both surgeons and radiologists due to the high clinical response up to dramatic pathological complete response (pCR) that may hinder proper localization of any residual tumoral tissue. So the radiopaque markers implantation at the tumor bed became a reliable and recommended method for tumor localization before surgical intervention or NAC. Many types of commercial clips and markers are available; however they are relatively of high cost and represent a considerable burden on the governments and the heath institute that made the researchers study cheaper alternatives as standard titanium based cholecystectomy surgical clips for tumor localization.ResultsThe study was conducted on 45 patients where 57 clips were inserted corresponding to number of lesions found in the total number of the patients. The response to Neoadjunvant chemotherapy was recorded and showed that 6 patients (about 13.3%) had complete radiological response after NAC, while 27 patients (60%) had regressive course after the treatment. The low cost surgical clips were evaluated by using sono-mammography and magnetic resonance imaging, and complications that occurred were recorded. Our study showed that in only 2 patients (3.5%) there was difficulty in clip visualization by Ultrasound during post-treatment follow up. In 45 patients, all the inserted clips (100%) were well visualized as small signal void on MRI at both T1WIs and T2WIs sequences, and the primary malignancy was easily visualized on both MRI and sono-mammography not interfering with the image interpretation and judgment. As regards the reported complications, our results revealed that in only 2 patients (3.5%) there was evidence of positive clip migration, while only 2 patients (3.5%) developed hematoma during the procedure as shown by ultrasound, Also 4 patients (7%) complained of pain only shortly after clip insertion. No other significant complications like infection or heat sensation developed either during the procedure or during MRI. The total price of the surgical clips was calculated with average cost of the needle about 10 US$ equivalent to 170 LE Egyptian pounds and the clip about 1.3 US$ or 20 Egyptian pounds, which is considered of lower cost when compared to the commercial breast markers of different companies with an estimated price range for clip = 75–200 US$ (average 90 US$). So insertion of surgical clips saved about 1135 Egyptian pounds equivalent to 73–75 US$ per clip placement.ConclusionWe concluded from our study that the use of breast markers are mandatory before NAC where Surgical clips can safely substitute the commercial tissue markers as tumor localizers as they are effective, safe, well tolerated, easily visualized on imaging and do not interfere with assessment of the treatment response, with no evidence of complications and are of low cost compared with the commercial breast clips.

Novel Intraoperative CT-Guided Marking Using O-arm System in Video-Assisted Thoracoscopic Surgery: An Easy, Safe, Time-Saving, Practical Method.

Objective: With the increased frequency of small lung tumor detection, there has been a similar increase in limited surgery, such as wedge resection. To identify such small lung tumors, we use a computed tomography (CT)-guided intraoperative marking method using the O-arm Surgical Imaging System. We retrospectively investigated its usefulness. Methods: Of 1,043 cases of thoracic surgery performed at our department between May 2017 and June 2021, O-arm System marking was used in 30 cases (2.9%), totaling 39 lesions. Tumor location was predicted preoperatively based on 3-dimensional CT and anatomic positioning. Visceral pleura near the tumor was marked with a metal clip, and the O-arm System was brought to the surgical site. CT was taken after the tumor side lung was fully re-expanded and clamped. After confirming the tumor and the clip locations, the clip was repositioned as necessary and marked in the same way. If the marking was successful, the clips were used as markers when performing lung resection. Results: Marking was successful in all cases. The average number of targets was 1.3, the average number of O-arm insertions was 1.3, and the average total number of marking clips was 2.6. In all cases, we checked the specimens, and if the tumor was palpable, the resection margin was also checked. No intraoperative or postoperative complications were observed in any patients. Conclusions: If the O-arm System is available, this technique is a noninvasive, simple, and useful method that could be widely used in clinical practice with a low dose of radiation.

MRI for an Acute Secondary Site Complication in Post-arthroplasty Management: Narrative Review of Safety Concerns for an Implanted Hip and Knee Joint.

Arthroplasty in the elderly may present with acute or late-onset complications unrelated to an implanted arthroplasty joint. Magnetic resonance imaging (MRI) evaluation of an acute onset complication in the immediate post-arthroplasty scenario presents safety concerns. An arthroplasty surgeon's dilemma relates to the loosening, heating, or migration of implanted hip or knee joints.We present a representational case scenario for discussion. A hip arthroplasty patient presenting with hemiplegia in the immediate postoperative period necessitated an MRI evaluation for the brain with an additional angiogram. A knee arthroplasty patient presenting with lower limb weakness in the immediate postoperative period necessitated an MRI evaluation of the brain. Loosening of surgical metallic clips used for wound closure and the instability or loosening of recently implanted hip and knee joints pose significant safety concerns for the arthroplasty surgeon. The confirmatory diagnosis of the secondary site complication in the acute post-arthroplasty perioperative period, however, allowed the allied super-specialist to plan the management protocol.A review of the literature suggests that the use of nonferromagnetic elements in implanted joints with the use of cement or the press-fit method of implantation during arthroplasty has high safety margins. The staples used for wound closure have significant strength to hold the wound without any disruption or dehiscence during the MRI imaging. The metallic artifacts associated with an implanted joint do not interfere in the evaluation of the secondary site MRI.MRI can be safely done in a well-fixed joint of non-ferromagnetic elements. The review of literature also suggests that MRI can be done even in the presence of skin staples for the assessment of an acute secondary site complication in a post-arthroplasty patient. The risk-to-benefit ratio though needs to be applied for imaging a secondary site.

Analysis of facial pressure generated by everyday masks using the finite element method

In the present work, a model based on the finite element method is formulated, with the purpose of measuring the facial pressure generated by everyday masks. The analysis includes the computational determination of the contact pressure generated by the mask on two head shapes that contemplate the anthropometric dimensions of the Colombian population between 20 and 59 years old, one represents the male sex and the other the female sex. The head model is divided into five parts (two cheeks, the forehead, the chin, and the back of the head), some of them contemplate layers of skin, muscle, fat tissue and bone, according to the anatomy of the human head. The mask is made up of three layers of different materials, a metal clip and two elastic bands that allow the mask to be adjusted to the face. The simulation process consists of placing the mask fully centered on the face and stretching the elastic bands until they are located at the back of the ears, thus generating facial contact between the mask and the head. The results obtained in the simulation indicate that the maximum pressure values are found in five specific points of the head.

Intraoperative Tumor Identification During Laparoscopic Distal Gastrectomy: a Novel Fluorescent Clip Marking Versus Metal Clip Marking and Intraoperative Gastroscope

BackgroundIn complete laparoscopic distal gastrectomy, the gastric resection line is difficult to determine due to a lack of tactile sensation. The use of intraoperative gastroscopy and intraoperative radiography has been reported, but the burden on personnel and technical complexity present impediments. In our department, based on lesion extent determined with preoperative gastroscopy, a fluorescent clip is used to mark the oral side of the lesion, which is resected after confirmation with a fluorescent laparoscopic system. In this study, we investigated the efficacy of fluorescent clip marking (FCM) in achieving an accurate resection line and reducing the operative time. MethodsFifty-six patients with gastric cancer who underwent complete laparoscopic distal gastrectomy from January 2018 to March 2021 were divided into two groups: the FCM group (n = 32) and the conventional metal clip marking and intraoperative gastroscopy (MCMG) group (n = 24). Short-term outcomes, including the resection margins, gastric resection time, and operative time, were compared and examined. ResultsThe fluorescent clips were visible in all cases, and all stumps were negative according to permanent preparations. The operative times for FCM and MCMG were 350 (216–533) vs. 373.5 (258–651) min, respectively, with no significant difference (p = 0.316), while the gastric resection times were 636.5 (321–2572) vs. 1457.5 (843–4973) s, respectively, and were significantly shorter in the FCM group (p < 0.0001). ConclusionsFCM shortened the gastric resection time and could possibly shorten the operative time. FCM is feasible and safe and can potentially be used as a tumor-marking agent to determine accurate surgical resection lines. Clinical Trial RegistrationExamination of Gastric Cancer, Research Ethics Committee of the Kawaguchi Municipal Medical Centre (Saitama, Japan), approval number: 2019-33. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf

Successful treatment of an iatrogenic biliary stricture using holmium laser "recanalization" and multistenting technique.

A 55-year-old woman admitted for jaundice 2 months after cholecystectomy underwent magnetic resonance imaging, which showed a common bile duct (CBD) stricture. Cholangiography during endoscopic retrograde cholangiopancreatography ([Fig. 1]) confirmed a tight stricture of the proximal CBD and lack of visualization of the intrahepatic bile ducts (IHBD). At cholangioscopy using SpyGlass DS (Boston Scientific), a complete stricture of the proximal CBD was observed with a metallic clip visible inside the CBD ([Fig. 2]). The on-call interventional radiologist performed a percutaneous transhepatic biliary drainage (PTBD) procedure in order to try a rendezvous approach. Percutaneous contrast medium injection confirmed dilated IHBD with complete absence of the proximal CBD lumen for a length of at least 5 mm. Multiple attempts to pass a guidewire through the stricture, both percutaneously and endoscopically, failed.

Renal pedicle control in laparoscopic donor nephrectomy: Evaluation of a single-center experience.

Introduction and Study Purpose:Renal pedicle control is a crucial period in laparoscopic donor nephrectomy (LDN). Till now, there is no standardized technique for renal pedicle control. Proper evaluation and investigation of the different ways of renal vessel control have to be done to avoid any calamitous event. We aim to prove the safety and reliability of the Hem-o-Lok clips for the renal vascular control in transperitoneal LDN.Methods:All LDNs or hand-assisted LDNs done between January 2016 and December 2018 were collected. The primary outcome was the safety of the Hem-o-Lok clips. The secondary outcomes were blood loss, ischemia time, hospital stay, cost, and operative time. The data were analyzed using SPSS 20, and a statistical package was conducted.Results:The data showed that 238 laparoscopic donor nephrectomies were done. The renal pedicle control during the 1st year was done using a vascular stapler for the artery (63 cases) and two polymer self-locking clips extra-large (XL) for the vein. Two events were reported in the form of mechanical failure. In the following 2 years, the artery was controlled using polymer self-locking clips large (L) few millimeters distal to the aorta and two metallic clips distal to it to increase the safety and stability of the vascular stump (175 cases). However, the vein was controlled by the two polymer self-locking clips XL. There was no reported intraoperative complications or events related to this way of pedicle control; there was no open conversion or blood transfusion required. There was no postoperative complication or collection in ultrasound.Conclusion:Using a combined polymer self-locking clip few millimeters distal to the aorta and two metallic clips distal to it for renal artery control in laparoscopic donor nephrectomies is cost-effective and safe. However, further and broader evidenced base studies are still needed to establish a standard technique for renal pedicle control.

Gold alloy metal clip versus nylon plastic clips of stress-free implant (SFI) bar used for immediately loaded 4-implant assisted mandibular overdentures. One-year randomized trial evaluating marginal bone loss and patient satisfaction.

Gold alloy metal clip versus nylon plastic clips of stress-free implant (SFI) bar used for immediately loaded 4-implant assisted mandibular overdentures. One-year randomized trial evaluating marginal bone loss and patient satisfaction.

Benefits of a standardized protocol for axillary management after neoadjuvant chemotherapy in a single center.

Introduction: The axillary lymph node status is one of the most important prognostic factors in breast cancer. For locally advanced tumors, neoadjuvant chemotherapy favors higher rates of breast lumpectomy and downstaging tumor burden of axilla. The aim of this study was to evaluate the use of a standardized image-guided protocol after neoadjuvant chemotherapy to enable sentinel node dissection in patients with axillary downstaging, avoiding axillary dissection. Methods: Retrospective cohort study of data collected from medical records of patients who underwent neoadjuvant chemotherapy in a single center, from January 2014 to December 2018. The protocol comprises the placement of a metal clip in positive axillary lymph node, in patients with up to two clinically abnormal lymph nodes presented on imaging. After neoadjuvant chemotherapy, and once a radiologic complete response was achieved, sentinel node dissection was performed using blue dye and radiotracer. Axillary dissection were avoided in patients whose clipped sentinel node were negative for metastasis and in patients with three identified and negative sentinel node dissection. Results: A total of 471 patients were analyzed for this study: 303 before and 165 after the implementation of the protocol; 3 cases were excluded. The rate of sentinel node dissection in clinical nodes positive patients was statistically higher in this group when compared to patients treated before the protocol implementation (22.8% vs. 40.8%; p=0.001). Patients with triple negative and HER2-positive tumors underwent sentinel node dissection more frequently when compared to luminal tumors (p=0.03). After multivariate analysis, the variables that were associated with a greater chance of performing sentinel node dissection were clinical staging, type of surgery performed and implementation of the axillary assessment protocol. Conclusions: The results showed that the use of an easily and accessible image-guided protocol can improve sentinel node dissection in selected patients, even if the lymph node was positive previously to neoadjuvant treatment.