Air pollution a leading cause of cancer - U.N. agency

LONDON/GENEVA (Reuters) - The air we breathe is laced with cancer-causing substances and is being officially classified as carcinogenic to humans, the World Health Organization's cancer agency said on Thursday.

The International Agency for Research on Cancer (IARC) cited data indicating that in 2010, 223,000 deaths from lung cancer worldwide resulted from air pollution, and said there was also convincing evidence it increases the risk of bladder cancer.

Depending on the level of exposure in different parts of the world, the risk was found to be similar to that of breathing in second-hand tobacco smoke, Kurt Straif, head of the agency's section that ranks carcinogens, told reporters in Geneva.

"Our task was to evaluate the air everyone breathes rather than focus on specific air pollutants," deputy head Dana Loomis said in a statement. "The results from the reviewed studies point in the same direction: the risk of developing lung cancer is significantly increased in people exposed to air pollution."

Air pollution, mostly caused by transport, power generation, industrial or agricultural emissions and residential heating and cooking, is already known to raise risks for a wide range of illnesses including respiratory and heart diseases.

Research suggests that exposure levels have risen significantly in some parts of the world, particularly countries with large populations going through rapid industrialization, such as China.

IARC reviewed thousands of studies on air pollution tracking populations over decades and other research such as those in which mice exposed to polluted air experienced increased numbers of lung tumors.

In a statement released after reviewing the literature, the Lyon-based agency said both air pollution and "particulate matter" - a major component of it - would now be classified among its Group 1 human carcinogens.

That ranks them alongside more than 100 other known cancer-causing substances in IARC's Group 1, including asbestos, plutonium, silica dust, ultraviolet radiation and tobacco smoke.

CARCINOGEN ENCYCLOPAEDIA

Air pollution is highly variable over space and time.

Loomis said there was relatively high exposure in Asia, South Asia, eastern North America, some places in Central America and Mexico, as well as North Africa.

But although both the composition and levels of air pollution can vary dramatically from one location to the next, IARC said its conclusions applied to all regions of the world.

"Our conclusion is that this is a leading environmental cause of cancer deaths," Dr. Christopher Wild, director of IARC, told the news briefing in Geneva.

IARC's ranking monographs program, sometimes known as the "encyclopedia of carcinogens", aims to be an authoritative source of scientific evidence on cancer-causing substances.

It has already classified many chemicals and mixtures that can be components of air pollution, including diesel engine exhaust, solvents, metals and dusts. But this is the first time that experts have classified air pollution as a cause of cancer.

Wild said he hoped the comprehensive evidence would help the WHO, which is revising its global 2005 guidelines on air quality. The U.N. agency makes on recommendations on public health issues to its 193 member states.

Asked why it had taken so long to reach the conclusion, he said that one problem was the time lag between exposure to polluted air and the onset of cancer.

"Often we're looking at two, three or four decades once an exposure is introduced before there is sufficient impact on the burden of cancer in the population to be able to study this type of question," he said.

(Editing by Alison Williams)

Reuters Health

Thyroid Surgery

General Information

Thyroid operations are advised for patients who have a variety of thyroid conditions, including both cancerous and benign (non-cancerous) thyroid nodules, large thyroid glands (goiters), and overactive thyroid glands. There are several thyroid operations that a surgeon may perform, including:

What is the thyroid gland?
The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.

1. excisional biopsy – removing a small part of the thyroid gland (rarely in use today);
2. lobectomy – removing half of the thyroid gland;
3. removing nearly all of the thyroid gland (subtotal thyroidectomy – leaving a small amount of thyroid tissue bilaterally or near-total thyroidectomy – leaving about one gm or cm of thyroid tissue on one side); or
4. total thyroidectomy, which removes all identifiable thyroid tissue.

There are specific indications for each of these operations. The main risks of a thyroid operation involve possible damage to important structures near the thyroid, primarily the parathyroid glands (which regulate calcium levels) and the recurrent and external laryngeal nerves (which control the vocal cords).

Questions and Considerations

When thyroid surgery is recommended, patients should ask several questions regarding the surgery including:

1. Why do I need an operation?
2. Are there other means of treatment?
3. How should I be evaluated prior to the operation?
4. How do I select a surgeon?
5. What are the risks of the operation?
6. How much of my thyroid gland needs to be removed?
7. What can I expect once I decide to proceed with surgery?
8. Will I lead a normal life after surgery?

Why do I need an operation?

The most common reason for thyroid surgery is to remove a thyroid nodule, which has been found to be suspicious through a fine needle aspiration biopsy (see Thyroid Nodule brochure). Surgery may be recommended for the following biopsy results:

1. cancer (papillary cancer);
2. possible cancer (follicular neoplasm); or
3. inconclusive biopsy.

Surgery may be also recommended for nodules with benign biopsy results if the nodule is large, if it continues to increase in size or if it is causing symptoms (pain, difficulty swallowing, etc.). Surgery is also an option for the treatment of hyperthyroidism (see Hyperthyroidism brochure), for large and multinodular goiters and for any goiter that may be causing symptoms.

Are there other means of treatment?

Surgery is definitely indicated to remove nodules suspicious for thyroid cancer. In the absence of a possibility of thyroid cancer, there may be nonsurgical options of therapy depending on the diagnosis. You should discuss other options for therapy with your physician.

How should I be evaluated prior to the operation?

As for other operations, all patients considering thyroid surgery should be evaluated preoperatively with a thorough and comprehensive medical history and physical exam, including cardiopulmonary (heart) evaluation. An electrocardiogram and a chest x-ray prior to surgery is often recommended for patients who are over 45 years of age or who are symptomatic from cardiac disease. Blood tests may be performed to determine if a bleeding disorder is present. Any patients who have had a change in voice or who have had a previous neck operation should have their vocal cord function evaluated preoperatively. This is necessary to determine whether the recurrent laryngeal nerve that controls the vocal cord muscles is functioning normally. Finally, if medullary thyroid cancer is suspected, patients should be evaluated for coexisting adrenal tumors (pheochromocytomas) and for hypercalcemia and hyperparathyroidism.

How do I select a surgeon?

In general, thyroid surgery is best performed by a surgeon who has received special training and who performs thyroid surgery on a regular basis. The complication rate of thyroid operations is lower when the operation is done by a surgeon who does a considerable number of thyroid operations each year. Patients should ask their referring physician where he or she would go to have a thyroid operation or where he or she would send a family member.

What are the risks of the operation?

The most serious possible risks of thyroid surgery include:

1. bleeding that can cause acute respiratory distress,
2. injury to the recurrent laryngeal nerve that can cause permanent hoarseness, and
3. damage to the parathyroid glands that control calcium levels in the body, causing hypoparathyroidism and hypocalcemia.

These complications occur more frequently in patients with invasive tumors or extensive lymph node involvement, in patients requiring a second thyroid surgery, and in patients with large goiters that go below the collarbone. Overall the risk of any serious complication should be less than 2%. However, the risk of complications discussed with the patient should be the particular surgeon’s risks rather than that quoted in the literature. Prior to surgery, patients should understand the reasons for the operation, the alternative methods of treatment, and the potential risks and benefits of the operation (informed consent).

How much of my thyroid gland neds to be removed?

Your surgeon should explain the planned thyroid operation, such as lobectomy or total thyroidectomy, and the reasons why such a procedure is recommended. For patients with papillary or follicular thyroid cancer many, but not all, surgeons recommend total or neartotal thyroidectomy when they believe that subsequent treatment with radioactive iodine might be beneficial. For patients with large (>1.5 cm) or more aggressive cancers and for patients with medullary thyroid cancer, more extensive lymph node dissection is necessary to remove possibly involved lymph node metastases.

Thyroid lobectomy may be recommended for overactive one-sided nodules or for benign one-sided nodules that are causing symptoms such as compression, hoarseness, shortness of breath or difficulty swallowing. A total or near – total thyroidectomy may be recommended for patients with Graves’ Disease (see Hyperthyroidism brochure) or for patients with enlarged multinodular goiters

What can I expect once I decide to proced with surgery?

Once you have met with the surgeon and decided to proceed with surgery, you will be scheduled for your pre-op evaluation (see above) and will meet with the anesthesiologist (the person who will put you to sleep during the surgery). You should have nothing to eat or drink after midnight on the day before surgery and should leave valuables and jewelry at home. The surgery usually takes 2-2½ hours, after which time you will slowly wake up in the recovery room. Surgery may be performed through a standard incision in the neck or may be done through a smaller incision with the aide a a video camera (Minimally invasive video assisted thyroiectomy) Under special circumstances, thyroid surgery can be performed with the assistance of a robot through a distant incision in either the axilla or the back of the neck. There may be a surgical drain in the incision in your neck (which will be removed the morning after the surgery) and your throat may be sore because of the breathing tube placed during the operation. Once you are fully awake, you will be moved to a bed in a hospital room where you will be able to eat and drink as you wish. Most patients having thyroid operations are hospitalized for about 24 hours and can be discharged on the morning following the operation. Normal activity can begin on the first postoperative day. Vigorous sports, such as swimming, and activities that include heavy lifting should be delayed for at least ten days.

Will I be able to lead a normal life after surgery?

Yes. Once you have recovered from the effects of thyroid surgery, you will usually be able to doing anything that you could do prior to surgery. Many patients become hypothyroid following thyroid surgery, requiring treatment with thyroid hormone (see Hypothyroidism brochure). This is especially true if you had surgery for thyroid cancer. Thyroid hormone replacement therapy may be delayed for several weeks if you are to receive radioactive iodine therapy (see Thyroid Cancer brochure).

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Minimal Parathyroid Surgery

The Minimally Invasive Technique Utilizing Intraoperative Nuclear Mapping

Written by James Norman MD, FACS, FACE

Also called: Minimally Invasive Radioguided Parathyroidectomy, or "MIRP" The technique of minimally invasive parathyroidectomy using intraoperative nuclear mapping (also called minimally invasive radioguided parathyroidectomy (MIRP)) was pioneered in

Also called: Minimally Invasive Radioguided Parathyroidectomy, or "MIRP"

The technique of minimally invasive parathyroidectomy using intraoperative nuclear mapping (also called minimally invasive radioguided parathyroidectomy (MIRP)) was pioneered in 1993-95 at the University of South Florida by Dr. James Norman, M.D.  During the past several years, the MIRP procedure has clearly become the preferred method of removing parathyroid tumors. More than 120 scientific articles have been published by more than a dozen US universities during this time showing that the MIRP has a higher success rate and lower complication rate than standard parathyroid surgery.  This minimal parathyroid surgical technique has gained wide acceptance as the most advanced, least invasive, and preferred method for operating on parathyroids.

The concept of minimally invasive radioguided surgery is simple: about 97% of patients with parathyroid disease have just one bad parathyroid...so give them a very small operation to remove just that one bad gland and leave the other 3 alone. In other words, change the big standard operation into something very small, fast, simple, and much less complicated for the vast majority of patients. The best news is that the cure rates reported to date for the MIRP procedure are as high or even higher than they would be if the more extensive and complicated operation was performed. This operation is possible because of the small probe shown in the picture. This probe will detect minute levels of radioactivity and so the surgeon uses it during the operation to find the hyperactive parathyroid tumor which is very easily made radioactive for about 4 hours with a very small (and very safe) dose of a special drug.

There are numerous potential advantages to minimally invasive radioguided parathyroidectomy.  First of all, the surgeon has a very good idea which one of the four parathyroid glands is hyperactive prior to beginning the operation. This allows the surgeon to operate on one very small area of the neck rather than exposing the entire neck and both sides of the thyroid. If the operation only takes place on one side of the neck, then the risks of damaging nerves and other important structures on the other side of the neck are eliminated and, therefore, the risks of this procedure are expected to be less than half of that seen during a complete neck exploration  (all reports of MIRPs in the medical literature have shown a lower complication rate). If you are contemplating parathyroid surgery, ask your doctors about this procedure, you will be glad you did.

Another advantage of the MIRP technique is that it is almost always performed without general anesthesia (put to sleep). The operation is typically performed through a 2.5cm (1 inch) incision (shown in yellow) rather than the usual 14 cm (6 to 10 inch) incision (shown in red). The surgeon is able to complete the operation through this smaller incision because he/she does not have to search for all four parathyroids to find the one which is overactive. Since the diseased gland is radioactive, the probe is placed into the wound every few minutes to direct the dissection right to where it is hiding. The probe also allows the adenoma to be removed in much less time. DON'T LET YOUR DOCTOR DO THE OLD FASHIONED OPERATION. THE RESULTS ARE NOT AS GOOD, AND THE COMPLICATION RATE IS MUCH HIGHER!  KEEP READING!

The average operative time to remove the diseased parathyroid gland using this technique is about 17 minutes as compared to an operation which can take up to three hours (or more!) when it involves exploration of both sides of the neck. Some centers (such as the Norman Parathyroid Clinic) are now reporting that as many as 75% of operations can be performed in under 15 minutes. The ability to do the procedure this quickly means that minimal anesthesia is needed, and unnecessary dissection within the neck is avoided. Combined, these advantages allow almost all patients to be sent home within an hour or two of the operation rather than spending one or two days in the hospital. Most institutions which are performing this type of surgery send virtually all patients home following this procedure (UPDATE: June 2005, Dr. Norman has reported sending 100% of his last 2,000 parathyroid patients home within 2 hours).  Even patients over 80 years old have had this procedure and sent home within an hour or two. The small wound heals quickly and only very rarely do patients need any prescription pain medications. Reported cure rates for this minimal approach are 99 percent, but most expect a long term cure rate of about 98 to 99 percent (Dr. Norman's reported and published cure rate is 99.75% -- remember, the standard operation has a cure rate of about 86 to 95%).

Advantages of Minimally Invasive Radioguided Parathyroidectomy (The MIRP Procedure)

• Local anesthesia or a very light general anesthesia using IV sedation (twilight anesthesia)  --  instead of general anesthesia where a breathing tube is put down the throat..
• 3/4 to 1.25 inch incision instead of 4 to 8 inch incision (thin people can expect a 1 inch or even smaller incision).
• Usually less than 30 minutes in the operating room vs. 2 to 5 hours. (average operating time is under 18 minutes)
• No risk to nerves and other structures on the "normal" side of the neck (risk to the voice-box nerve should be less than 1/4 of the risk if performed by the old "exploration").
• Less than 1/4 of the potential complications than the standard operation.
• Much smaller overall operation so less pain (only Tylenol or aspirin needed).
• Return to normal activities usually by the next day (instead of a week or so of recuperation time). Nearly zero recuperation time needed.
• Usually home in an hour or 2 (vs. 1 to 3 days in the hospital).
• Most patients go out to eat the evening of surgery.
• Significantly less expensive than the standard operation. *
• Cure rate significantly higher than the standard operation.
• Dramatically reduced chance of surgery not helping the problem.
• Zero risk of hypoparathyroidism (a rare complication seen when all parathyroids are removed)

* Eight publications in medical journals have now shown that the cost of performing a MIRP is significantly less than the standard operation; as much as 1/3 the overall cost! The most recent one (Journal of Head and Neck Cancer, November 2003) shows it can be about 1/2 the cost of the old fashioned operation)

Who is a Candidate for Minimally Invasive Parathyroidectomy?

This new approach to parathyroid surgery has taken the surgical and endocrinology specialties by storm.  The cure rate is significantly higher than any other parathyroid operation and the complication rate is near zero (significantly less than 1 percent when performed by expert parathyroid surgeons).  This is changing the way all doctors look at this disease.  Since hyperparathyroidism can now be fixed easily for the vast majority of patients in less than 20 minutes, most endocrinologists are sending all of their patients for this minimal operation.  They feel it is riskier to wait around and potentially develop osteoporosis or kidney stones than it is to have this procedure.  Besides, the operation makes the majority of people feel better and enjoy life more!

This technique is revolutionizing the way parathyroid surgery is performed.  More and more surgeons are being trained in radioguided surgery for breast cancer and malignant melanoma, as well as parathyroids and so radioguided surgery is becoming much more common.  The results of this minimal approach has now been proven to be BETTER than the gold standard operation and they are embracing it fully. A recent study of endocrinologists has shown that this minimal parathyroid operation is the preferred method to remove parathyroid tumors.    View an abstract of the opinions of nearly 800 endocrinologists surveyed regarding MIRP (click here). * 96% of endocrinologists would travel to another state to have a MIRP by an expert if they needed a parathyroid operation!

Virtually all patients with hyperparathyroidism can have a Mini-Parathyroid operation (MIRP) when performed by one of the few extremely experienced parathyroid surgeons in the world. Those patients in whom a high quality Sestamibi scan shows a single adenoma as the cause for the primary hyperparathyroidism are extremely good candidates for minimally invasive parathyroidectomy, and their operations should be expected to last about 15 - 25 minutes.. About 85 - 90 % of all patients with primary hyperparathyroidism will localize in this manner and can have this very fast out-patient procedure. The other ~ 10 - 15 % will not localize on their Sestamibi (a "negative Sestamibi Scan) and will likely need all four parathyroid glands examined, however, with radioguided techniques (MIRP), this can still be done in under 25 minutes in almost all patients, through the same 1 inch incision. YES, ALL PATIENTS CAN AND SHOULD HAVE A MINI- PARATHYROID OPERATION. YES,  ALL PATIENTS, REGARDLESS OF THEIR SESTAMIBI SCAN RESULTS CAN HAVE A MINI OPERATION IF THEIR SURGEON KNOWS HOW TO DO IT !  You may be better served by finding an expert. As you will read on other pages of this website, there is no other operation that is more dependent upon the experience of the surgeon. Parathyroid surgery is all about experience, so shop for your surgeon very smartly!

Read what patients say about having a MIRP mini-parathyroid operation.  These are patients just like you who never heard of a parathyroid gland until they got this disease. They don't know anybody else who has had this disease, and their doctor doesn't see to much of it either.  Read about patients who have had their entire problem cured in 30 minutes or less!  CLICK HERE.

Has This Technique Been Published?

This is a frequently asked question, and it should be! Physicians have long believed that new medical procedures / drugs should be studied scientifically and subjected to critical review by other physicians and experts in the field. The answer to this question is YES. So as not to clutter up this page, we put this information on another publication page.

We are often asked "If this is the best way to do parathyroid surgery, then why doesn't every surgeon do it this way?" Well, there are several reasons:  Since this is a rare disease and most surgeons see only one case of parathyroid disease every year or two it doesn't make economic sense for the hospital to purchase the equipment.. Typically, the radioguided probe will cost $150,000 and this is simply too much if it is to be used only once or twice per year. Secondly, the surgeon is required to take a training course to use radioguided techniques in the operating room. These courses are expensive, and require the surgeon to miss 2 days of work. Again, it is not economically sound for a surgeon to do this if he/she only sees 1 or 2 patients per year with this disease. Finally, the surgeon has to take courses and yearly updates on using radioactive materials. This can be a big pain in the rear!  It all comes down to economics and experience. If the patients are not demanding radioguided surgery, and the surgeon / hospital are not performing more than a dozen or so parathyroid operations per year, then it doesn't make economic sense to perform radioguided parathyroid surgery.

The biggest reason that all surgeons don't do mini-parathyroid surgery, however, is because this is a rare disease. It is un-real to expect every surgeon to be an expert for a rare disease. In fact, if you think there is a parathyroid expert in every large city, you are wrong. There cannot be an expert in every city for a rare disease. Every surgeon gets to do 0 to 2 parathyroid operations per year... hardly enough practice to be an expert.  Why do they do it then??? Because it is a tricky operation it pays very well. Your general surgeon won't say no to you... there is too much money involved.

Parathyroidectomy

What are the parathyroid glands?

The parathyroid glands are four, small, pea-shaped glands that are located in the neck on either side of the trachea (the main airway) and next to the thyroid gland. In most cases there are two glands on each side of the trachea, an inferior and a superior gland. Fewer than four or more than four glands may be present, and sometimes a gland(s) may be in an unusual location. The function of the parathyroid glands is to produce parathyroid hormone (PTH), a hormone that helps regulate calcium within the body.

Illustration of the Parathyroid Glands

What is a parathyroidectomy?

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Parathyroidectomy is the removal of one or more of the parathyroid glands, and it is used to treat hyperparathyroidism.

What is hyperparathyroidism?

Hyperparathyroidism is a condition in which the parathyroid glands produce too much PTH. If there is too much PTH, calcium is removed from the bones and goes into the blood, and there is increased absorption of calcium from the intestine into the blood. This results in increased levels of calcium in the blood and an excess of calcium in the urine. In more serious cases, the bone density will diminish and kidney stones can form. Other non-specific symptoms of hyperparathyroidism include depression, muscle weakness, and fatigue. Every effort is made to medically treat or control these conditions prior to surgery. These efforts include avoiding calcium rich foods, proper hydration (intake of fluids), and medications to avoid osteoporosis.

What causes hyperparathyroidism?

There are two types of hyperparathyroidism, primary and secondary. The most common disorder of the parathyroid glands and one that causes primary hyperparathyroidism, is a small, tumor called a parathyroid adenoma. A parathyroid adenoma is a benign condition in which one parathyroid gland increases in size and produces PTH in excess. (As opposed to parathyroid adenoma, it should be noted that malignant tumors of the parathyroid glands, that is, cancer, is very rare.) In most situations patients are unaware of the adenoma, and they are found when routine blood test results show an elevated blood calcium and PTH level. Less commonly, primary hyperparathyroidism may be caused by overactivity of all of the parathyroid glands, referred to as parathyroid hyperplasia.

With secondary hyperparathyroidism, the secretion of PTH is caused by a nonparathyroid disease, usually kidney failure.

When is a parathyroidectomy necessary and how is it performed?

Parathyroidectomy is necessary when calcium levels are elevated, if there is a complication of hyperparathyroidism (such as kidney stones, osteoporosis, or bone fractures), or if a patient is relatively young. Tests such as a high-resolution ultrasound or a nuclear medicine scan (called a sestamibi scan) help to direct the approach preoperatively or intra-operatively by identifying the location of the overactive, enlarged gland. During a parathyroidectomy, the surgeon delicately removes one or more of the tiny parathyroid glands. In some situations, both sides of the neck are explored, while in other cases a direct approach is made through a small incision (referred to as a minimally invasive parathyroidectomy). In rare situations, the offending gland cannot be found. (A portion of a gland also may be transplanted to another site in the neck or the arm to preserve parathyroid function.)

Whereas preoperative tests help to identify hyperparathyroidism and to direct the surgical approach, PTH levels obtained during parathyroidectiomy help to guarantee the successful resection of the abnormal gland by demonstrating a return of the PTH levels to normal after the suspected parathyroid adenoma is removed. Using this method, a PTH determination is obtained immediately prior to the resection and compared to a PTH determination done ten minutes after the resection.

What are the risks of parathyroidectomy?

The anatomy of the parathyroid glands is complicated by two important structures: the recurrent laryngeal nerve and the thyroid gland. The recurrent laryngeal nerve is a very important nerve that runs very close to or through the thyroid gland next to the parathyroid glands. This nerve controls movement of the vocal cord on that side of the larynx, and damage to the nerve can weaken or paralyze the vocal cord. Weakness or paralysis of one vocal cord causes a breathy weak voice, and difficulty swallowing thin liquids. Weakness or paralysis of both vocal cords causes difficulty breathing. In most situations, a special breathing tube is used that rests in the larynx (voice box) between the vocal cords and is designed to allow for the continued monitoring of their function. In rare situations, the parathyroid adenoma is found within the thyroid gland, and it is necessary to remove the thyroid gland as well. The main goal of the parathyroidectomy operation is to remove the offending gland(s) while protecting the remaining normal parathyroid glands as well as the recurrent laryngeal nerves and the thyroid gland.

Surgery may be unsuccessful, that is, the hyperparathyroidism may not be cured and there may be complications of the surgery. Because individuals differ in their response to surgery, their reaction to the anesthetic and their healing following surgery, there can be no guarantee made as to the results or the lack of complications. Furthermore, the outcome of surgery may depend on preexisting or concurrent medical conditions.

What are the possible complications of parathyroidectomy?

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The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. They are listed here for your information only, not to frighten you, but to make you aware and more knowledgeable concerning parathyroidectomy. Although many of these complications are rare, all have occurred at one time or another in the hands of experienced surgeons practicing community standards of care. Anyone who is contemplating surgery must weigh the potential risks and complications against the potential benefits of the surgery or any alternative to surgery.

1. Damage to the recurrent laryngeal nerve with resultant weakness or paralysis of the vocal cord or cords: This is a rare but serious complication. Unilateral weakness results in a weak, breathy voice, and there will be problems swallowing. A second surgical procedure can alleviate many of the symptoms of unilateral vocal cord paralysis. Bilateral vocal cord paralysis results in a relative normal voice; however, there is difficulty breathing, and the patient may ultimately require a tracheotomy. Every effort is made to protect the recurrent laryngeal nerve. Temporary vocal cord weakness occurs much more frequently than permanent vocal cord weakness, and it usually will resolve after several days or within a few weeks. Rarely, a malignant tumor has already invaded the nerve and has caused vocal cord weakness or paralysis.
2. Bleeding or hematoma: In rare situations, a blood transfusion may be necessary because blood is lost during surgery. Patients can choose to have autologous blood (their own blood) or blood from a friend or relative collected in advance of the surgery in case a transfusion is necessary. The surgeon can make arrangements for patients interested in these options.
3. Damage to the remaining parathyroid glands with resultant problems in maintaining calcium levels in the blood: In most situations, you only need one functioning gland to have normal calcium levels. In the rare event that all glands are removed, blood calcium levels may fall, and patients may need to take calcium supplementation for the rest of their lives.
4. Need for further and more aggressive surgery: In some cases, surgical exploration fails to identify the abnormal parathyroid gland or multiple abnormal glands may be present. Further and more aggressive surgery may be necessary, such as an extensive surgical exploration of the neck or chest.
5. Need for a limited or total thyroidectomy: In rare situations, the abnormal parathyroid gland is within the thyroid gland itself or an unexpected thyroid carcinoma, a malignant cancer, is identified. In such situations, much or all of the thyroid gland must be removed, and there may be a need for life-long thyroid hormone treatment.
6. Prolonged pain, impaired healing, need for prolonged hospitalization, permanent numbness of the neck skin, poor cosmetic result, and/or scar formation.
7. Recurrence of the tumor or failure to cure the tumor despite effective therapy.

What else do you need to know before parathyroidectomy?

Parathyroidectomy usually takes up to three hours. In most situations, the surgery is performed at a hospital or at an outpatient surgery center. An anesthesiologist provides anesthesia and monitors patients throughout the surgery. The anesthesiologist calls the night before surgery to review each patient's medical history or talks to the patient on the morning of the surgery. If preoperative laboratory studies are ordered, they are done several days before the surgery to allow enough time for the results to be obtained and sent to the surgeon and anesthesiologist.

Most patients are told not take aspirin or any product containing aspirin for 10 days prior to surgery in order to prevent aspirin from increasing bleeding at the time of surgery. Nonsteroidal antiinflammatory medications, or NSAIDs, (such as Advil, Motrin, Ibuprofen, Naprosyn, Aleve, etc.) also are stopped several days prior to the surgery for the same reason. It is important to note that many over-the-counter products contain aspirin or ibuprofen, so it is important that patients carefully check all medications that they are taking. If there is any question about a medication, patients should call their doctor's office or consult with their pharmacist. Tylenol is an acceptable pain reliever if a pain reliever is needed prior to surgery. Doctors often give patients their prescriptions for postoperative medications at the preoperative visit so that they may have them filled prior to the surgery. Surgeons may advise purchasing calcium-containing antacids such as Tums-Extra Strength tablets in case the blood calcium drops after surgery and calcium supplements are needed. The amount and duration of supplementation is determined by the surgeon.

Patients do not eat or drink anything for approximately six hours prior to the time of surgery. This includes even water, candy, or chewing gum. Anything in the stomach increases the chances of an anesthetic complication.

Smokers should make every effort to stop smoking (or at least reduce the number of daily cigarettes). This may improve the healing process and reduce postoperative coughing and bleeding.

What about care after parathyroidectomy?

After surgery, patients go to the recovery room where nurses monitor them for about one hour. In most situations patients spend one night in the hospital, although some patients undergoing a minimally invasive parathyroidectomy may go home the same day. A friend or family member usually is required to pick patients up from the surgical facility if they are going directly home. It is a good idea for someone to be at home with the patient for the first night.

Patients' necks may be swollen and bruised after surgery, and in most instances there will be a bandage wrapped around the neck. Bandages usually are removed one or two days following surgery. There may be a small plastic drain exiting through the skin. If so, the drainage of fluid from the drain will be monitored in the recovery room or hospital. Sometimes patients may even go home with a drain in place after the nursing staff teaches them how to manage the drain. Sutures taped to the neck should not be cut or trimmed.

Starting several hours after surgery and possibly for several days, blood calcium levels usually are monitored. It is not uncommon for there to be a fall in the blood calcium level following surgery. (The remaining parathyroid glands are "sleepy" following surgery.) As a result, patients may need to take supplemental oral calcium for several days or weeks following surgery. Permanent calcium problems are rare. If patients experience numbness and tingling of the lips, arms, or feet, and or twitching of the muscles--symptoms of low blood calcium--they should contact their surgeon or endocrinologist immediately. In most situations in which these symptoms occur, surgeons will ask patients to take supplemental calcium, such as in Tums-Extra Strength, after surgery. This helps to replenish calcium that is moving back into the bones.

Numbness, slight swelling, tingling, discoloration, bumpiness, hardness, crusting, tightness, and a small amount of redness around the incision are a normal findings after surgery and should improve with time. It is usually alright for patients to wash their face, neck, and hair after the bandages have been removed. Excessive scrubbing of the wound should be avoided, and a gentle soap and shampoo should be used.

In the hospital and after going home, patients generally lie in bed and rest with their head elevated on 2-3 pillows. By keeping their head elevated above their heart, swelling of the neck due to edema may be lessened. Patients get out of bed with assistance to use the bathroom, however. It is good to avoid straining when having a bowel movement, and, if constipation is a problem, a stool softener or a gentle laxative is a good idea.

It may be better to eat a light, soft, and cool diet as tolerated after recovery from the anesthetic. Even though patients may be hungry immediately after surgery, it may be best to go slowly to prevent postoperative nausea and vomiting. Occasionally, patients may vomit one or two times immediately after surgery. If vomiting persists, the doctor may prescribe medications to settle the stomach. A good overall diet with ample rest promotes healing.

Antibiotics often are prescribed after surgery. Patients should finish all the pills that have been ordered. Some form of a narcotic pain medication usually will be prescribed and is to be taken as needed. Patients who take narcotics should not drive. If there is nausea or vomiting postoperatively, patients may be prescribed medications such as promethazine (Phenergan). If patients have any questions or feel that they are developing a reaction to any of the medications, it is important that they consult with their doctor. Patients should not take any other medication, prescribed or over-the-counter, unless they have discussed it with their doctor.

Sutures are removed approximately 7 days after surgery. If not already scheduled, patients should call the surgeon's office to arrange for a follow-up visit. Routine follow-up care depends on the nature of any problems that develop. After healing has occurred, patients usually return to their endocrinologist for long-term monitoring of their calcium levels.

Patients may go back to work or school only when their doctors say they may. Patients probably should rest for the first week following surgery and avoid excessive talking, smiling, hard chewing, strenuous activities, lifting heavy objects, and bending over. Alcohol and tobacco should be avoided because they may prolong swelling and healing. Tanning is discouraged for 6 months after surgery; if patients must be in the sun they should use a number 15 or greater sun block and consider wearing a hat. Make-up may be used anytime after surgery.

After 3 weeks, if there are not problems with bleeding or excessive swelling, it is reasonable to resume exercise and swimming. To allow for postoperative care, it is probably a good idea not to travel out of town for three weeks after surgery.

When should patients contact their doctor?

Patients should contact their doctor if they notice:

1. A sudden increase in the amount of bruising and pain associated with excessive swelling of the neck and difficulty breathing.
2. A fever greater than 101.5 degrees F that persists despite increasing the amount of fluid they drink and acetaminophen (Tylenol). (A person with a fever should try to drink approximately one cup of fluid each waking hour.)
3. Drainage from the wound.
4. Spasms or severe cramps in the muscles or twitching of the face. If this occurs, patients should call their surgeon immediately and be ready to have their blood calcium level determined.

Reconstruction after breast cancer: It's not a boob

It’s been nearly a month since my last surgery and the new girls are still a little scary looking. Righty’s recovering from a post-op infection that had me in the hospital on IV antibiotics for two days. Lefty’s missing most of her nipple, a casualty of my first surgery back in May.

They’re bruised and bandaged and look a bit like they’ve been in a bar fight. But they’re mine, thanks to the wonders of breast reconstruction surgery. Or as it’s popularly known, my “free breast cancer boob job.”

I’m being sarcastic, of course. Only a fool would confuse breast reconstruction with a boob job, but sadly, there seem to be a lot of fools out there.

I should know; I used to be one of them, until a radiologist uttered those three little words that have made such a difference to so many peoples’ lives: You have cancer.

After that, everything changed, including my understanding of what women have to go through to get their girls back. And trust me, it’s not easy and it’s not quick.

Unless you’re lucky. Or Angelina Jolie.

Jolie had immediate reconstruction after her prophylactic mastectomy. Breast tissue comes out, tissue expanders go in, then the TEs (as they're called) are slowly filled with saline until they can be surgically swapped for implants.

The actress didn’t have breast cancer – at least not yet – so she didn’t have to worry about any of the complications that can arise when you perform multiple surgeries on someone whose immune system has been compromised by chemo or blasted by radiation.

As a result, her recon took about three months.

Lisa Duncanson’s “immediate reconstruction,” on the other hand, began four years ago. And it’s still going on.  

Lisa, who teaches law in Orange County, Calif., had tissue expanders put in at the time of her double mastectomy that were inflated over the course of two months, just like Jolie.

But before her surgery, she had chemo. And after it, she had radiation, which is great for upping your survival rates but not exactly Oil of Olay when it comes to your skin. Radiation changes it, making it more sensitive, harder to heal, harder to stretch. As a result, one of Duncanson’s tissue expanders broke through her skin. Three infections, two hospitalizations, months of antibiotic IV infusions and two “lat flap” surgeries later, and her breasts are still a work in progress.

Courtesy of Lisa Duncanson

Lisa Duncanson was hospitalized for an infection acquired after her second surgery.

“Oh yes, I love the boob job I’m getting,” Duncanson joked to me on the phone, then went on to explain how she felt she’d been “sold a bill of goods” by doctors who weren’t completely forthcoming about the risks.

“There seems to be this almost paternalistic undercurrent to it all,” she said. “That we as women can’t handle the truth about what is really going to happen to our bodies and our breasts.”

And what really happens is often not pretty.

You’re thrown into a world of wounds and drains and aspirating syringes that look like something you’d use to impregnate livestock. Tissue dies, incisions refuse to heal and your body can be racked by infections that can last for weeks, even months.

Recent studies calculate the post-op infection rate for breast implant reconstruction (the most popular), as high as 35 percent (it’s about 2.5 percent for regular old breast augmentations) with about a 20 percent failure rate for the same procedure with radiation thrown in. As for other types of recon, a May 2013 study of 277 survivors who underwent “lat flap” reconstruction, calculated post-op complication rates at 33.5 percent for the breast site and 22.3 percent for the donor site.

“Every patient who had reconstruction said it was the biggest challenge of everything – mastectomy, chemo and radiation,” said Dr. Joanne Weidhaas, a Yale Cancer Center radiation oncologist currently researching genetic mutations.

Yet reconstruction is often cast as the “fun” part of breast cancer.

“People say things like ‘You’re going to be 80 and have the perkiest boobs in the pool!’” said Duncanson. “Even my first plastic surgeon was like, ‘You’re going to have even better boobs!’”

Bigger, possibly. But better?

Courtesy of Lisa Duncanson

Lisa Duncanson has recovered from her breast reconstruction, and is back to playing gigs with her blues band.

Reconstructed breasts have no sensation, unless you’re lucky and some of your nerves grow back. And many don’t have nipples unless your plastic surgeon constructs them, which, again, is tricky if you’ve had radiation. Then there are the scars -- on your breasts, sure, but also on your stomach or back or butt if your surgeon needs to borrow tissue and/or muscle to make a breast mound. And let’s not forget the side effects like capsular contracture, adhesion pain, ripples and ruptures. Or the weeks (or months) of recovery.

Sure, many women come through with zero complications and lovely, natural-looking breasts (Angelina Jolie may or may not be one of them). But others are left with a “patchwork mess,” as Duncanson calls her reconstructed girls, breasts that look good in clothes but not so much otherwise.

Weidhaas would like to see more coordination between plastic surgeons and radiation oncologists so patients “don’t have their cancer come back and … don’t have a bad cosmetic outcome.” She’d also like to see more research conducted on why some people are more at risk for radiation’s skin tightening side effects.

“There’s definitely a genetic component,” she said.

Wonderful ideas, all.

Reconstruction’s not a perfect science, especially for those of us who’ve gone through treatment. But it’s come a long ways and new innovations, like tissue engineering, are ever in the works. I’ll admit my delayed reconstruction’s been a slog, even though I did my homework and thought I was prepared. Treating the whole process like chemo or radiation has definitely helped me power through my two surgeries and the resulting “minor” complications.  

But I still have moments when I question whether it’s all worth it. Many survivors do and decide to skip the extra surgeries and the grief and live the rest of their lives breast-free.

At the end of the day, though, I’d rather roll the reconstruction dice and do what I can to get my girls back, to get my own back – or something close to it, anyway. For me, it’s about letting cancer know it’s not going to waltz off with two of my favorite body parts. For me, it’s about fighting back.

And, yes, healing.

“I know women who adapt but I did not adapt,” said Lani Horn, a 42-year-old math education professor from Nashville, whose three recon surgeries resulted in new breasts -- and lymphedema. “I always felt incomplete. Plus my kids would say things like my body wasn’t as cuddly as it used to be.”

Like me, and so many others, Horn just wanted to live her life without being “whacked over the head by cancer” every time she passed a mirror. And she's happy with her decision. 

“Even with all my kvetching, I’m really glad I did it,” she said.

And I’m right there with her, despite the fact I’m currently rocking a set of Frankenboobs (just in time for Halloween!). They’re not pretty but then, they haven’t fully healed. Nor have I. But I will. I need to. I’ve got more surgery ahead.

Reconstruction, as they say, is a long road.

And the next person who refers to it as a “boob job” is going to get smacked with an IV pole.

Tissue Flap Surgery for Breast Reconstruction

Tissue flap surgery is a way to rebuild the shape of a breast using skin, fat, and muscle from another part of the body. It is usually done after part or all of the breast is removed (mastectomy) because of cancer. It may also be done for women who have problems with breast development.

Tissue flap surgery is also called autologous tissue reconstruction. "Autologous" means the tissue used in the surgery comes from your own body.

Breast reconstruction usually takes more than one surgery. The first surgery may be done during the same surgery as mastectomy, or it may be done later as a separate procedure. The nipple and the brown area around it (areola) are created at a later time.

Tissue flap surgery is done by a plastic surgeon. The breast surgeon who does your mastectomy can refer you to a plastic surgeon with special training in breast reconstruction.

You will meet with the plastic surgeon before your mastectomy to discuss the best procedure for you. The surgeon can show you pictures of other women who had the surgery you are considering. Ask to see both the best and worst results so you can get a better idea of what can happen. You can also ask to talk to women who have had the surgery.

If you are not comfortable with the surgeon or the recommended treatment, you can see another surgeon to get a second opinion.

Types of tissue flap surgery

Tissue flap surgery may be done in two ways:

• "Pedicle flap" means the flap of tissue from the back or belly is moved to the chest without cutting its original blood supply. The tissue is pulled under the skin up to the chest area and attached.
• "Free flap" means the tissue and blood vessels are cut. After the flap is in place, the surgeon sews the blood vessels in the flap to blood vessels in the chest area. This requires careful surgery using a microscope.

There are different types of tissue flap surgery, named for the area of the body where the tissue is taken.

• TRAM (transverse rectus abdominis muscle) flap is one of the most common types of flap surgery. The surgeon takes muscle and tissue from the lower belly and moves it to the chest area. This reduces the amount of fat and skin in the lower belly and results in a "tummy tuck." TRAM may be done as either a pedicle flap or a free flap.
• Latissimus dorsi (LD) flap is a type of pedicle flap surgery. It uses muscle, fat, and skin from the upper back that is pulled under the skin to the chest area. The scar on the back can be placed at the bra line to make it less visible. Sometimes an implant is placed during the same surgery to make the breast larger.
• DIEP (deep inferior epigastric artery perforator) flap is a free flap similar to TRAM. The surgeon takes fat and skin from the lower belly area but doesn't use the muscle. By saving the muscle, it helps avoid later belly weakness. Like TRAM, it results in a "tummy tuck."
• SIEA (superficial inferior epigastric artery) flap is similar to the DIEP flap. But with this surgery, the surgeon doesn't cut through the belly muscles to get the artery used for the new breast. Like DIEP, it results in a "tummy tuck."
• Gluteal free flap is a free flap that uses muscle, fat, and skin from the buttocks to create a new breast. This may be a good choice for thin women who don't have enough belly tissue for DIEP or TRAM.

What To Expect After Surgery

Tissue flap surgery is done using general anesthesia, so you sleep during the procedure. Depending on the procedure, the surgery may take several hours to complete, and you may need a blood transfusion.

When you wake up from surgery, you will have bandages over the surgery sites, and you may wear a special bra that holds your bandages in place. You will also have drainage tubes to collect fluid and keep it from building up around the surgery sites.

You will stay in the hospital about 5 days so your doctor can be sure there is good blood supply to the skin over the reconstruction. A physical therapist may show you exercises while you are still in the hospital. These can help keep your shoulder from getting stiff.

Most woman have soreness, redness, and swelling in the breast and the area where the tissue was taken. The swelling may last for several weeks. You may need pain medicine for a week or two. Your doctor may also prescribe antibiotics to help prevent infection.

You may be able to go back to work or your normal routine in 3 to 6 weeks. Most women need to avoid strenuous activity for several weeks.

Why It Is Done

Tissue flap surgery is usually done to restore the appearance of a breast after mastectomy. It may also be done for women who have problems with breast development.

Breast reconstruction may help a woman feel better about her appearance. Some women say it helps them feel better about their bodies, more alive, feminine, and sexual—and happier about life.

How Well It Works

Most women who have tissue flap surgery are happy with the results. Compared to breast reconstruction with implants, tissue flap procedures require a longer surgery and recovery time but result in a more natural-looking breast.

Breast reconstruction cannot restore normal feeling to your breast, but with time, some feeling may return.

Risks

Many of the risks associated with breast reconstruction are the same as those with any surgery: infection, poor wound healing, bleeding, or a reaction to the anesthesia used in surgery.

Other risks associated with tissue flap surgery include:

• Tissue death if blood supply to the flap is not restored. This could cause the need for more surgery.
• Collection of blood or clear fluid in the wound.
• Ongoing pain or discomfort in the breast area.
• Muscle weakness in the area where muscle is removed.
• Abnormal scarring.

Some women are at higher risk for problems, so tissue flap surgery may not be a good choice for them. This includes women who:

• Are obese (BMI over 35).
• Have high blood pressure.
• Have diabetes.
• Smoke.
• Are in poor health.

What To Think About

If you will need to have radiation therapy after mastectomy for breast cancer, your surgeon may want you to wait and have reconstruction after your treatment. Radiation can affect the success of tissue flap surgery.

If you can choose when to have surgery, be sure to discuss the pros and cons of having it at the same time as mastectomy and the pros and cons of waiting until later. Some women want to get started with reconstruction right away. Others may feel overwhelmed by a cancer diagnosis, so they put off the decision to have reconstruction until they feel ready to deal with it. Be sure you understand your options.

Getting a breast implant is easier and quicker to recover from than tissue flap surgery. Some women choose to get a breast implant first and have tissue flap surgery later, when they feel stronger or have more time.

Breast Implant Surgery for Breast Reconstruction

It is important to know that your breasts will look different after surgery. Your new breast may feel firmer and look rounder or flatter than your other breast. Some women have surgery on the other breast to make them look as much alike as possible.

Breast reconstruction can be a long process. It may take several months for your breast to heal. And it may be a year before you can see the final result.

The incisions will leave scars on your breasts and wherever the tissue was taken. These will fade with time. The surgeon will try to make incisions that leave as few scars as possible.

Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction. Check with your insurance company to find out what your costs will be.

Modified Radical Mastectomy

When doctors treat breast cancer, their goal is to remove all of the cancer -- or as much of it as possible. Surgery is one of the mainstays of treatment, and today a procedure called modified radical mastectomy (MRM) has become a standard surgical treatment for early-stage breast cancers.

Modified radical mastectomy is especially helpful for early-stage breast cancer that has spread to the lymph nodes. Studies show that MRM is just as effective as radical mastectomy, but not nearly as disfiguring.  MRM spares one or both of the chest muscles, preventing an unsightly hollow in the chest that is common after a traditional radical mastectomy.

Recommended Related to Breast Cancer

About This PDQ Summary

Purpose of This Summary This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of male breast cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. Reviewers and Updates This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial...

Read the About This PDQ Summary article > >

What Is Modified Radical Mastectomy?

During a modified radical mastectomy, the surgeon removes the breast (including the skin, breast tissue, areola, and nipple) and most of the lymph nodes under the arm. The lining over the large muscle in the chest called the pectoralis major is also removed. However, this surgery spares the pectoralis major muscle itself.

MRM surgery tries to preserve enough healthy tissue and skin for a surgeon to perform breast reconstruction surgery in women who want to have it done.

What to Expect During an MRM

A modified radical mastectomy takes about two to four hours. The surgery might take longer if you have breast reconstruction surgery done immediately afterward.

While you are under general anesthesia, the surgeon will make a single incision across one side of the chest. The skin will be pulled back. Then the doctor will remove the entire breast tissue, the lining over the pectoralis major, as well as some of the lymph nodes under your arm.  Finally, the doctor will close the incision.

The goal is to remove the cancer while preserving as much of the skin and tissue as possible so that you can have breast reconstruction. The surgeon also will try to avoid damaging nearby blood vessels and nerves.

Although research has found modified radical mastectomy to be generally safe and effective, like all surgical procedures it can have risks, which include:

• Bleeding
• Infection
• Swelling of the arm
• Pockets of fluid forming underneath the incision (seromas)
• Risks from general anesthesia

Some people experience numbness in the upper arm, which is caused by damage to small nerves in the area where the lymph nodes are removed. There is a good chance that you will regain most of the feeling in your arm over time.

The lymph nodes that are removed will be sent to a lab for examination to determine whether the cancer has spread.

After a Modified Radical Mastectomy

Once your surgery is complete, you will need to stay in the hospital for one or two nights. Thin plastic tubes will be placed in your breast area to drain off any fluid. These drains are attached to small suction devices. The drains will be removed about a week after your surgery. The hospital staff will show you how to care for the tubes until they are removed.

After a Modified Radical Mastectomy continued...

If you are feeling pain after your surgery, your doctor will prescribe pain medication for a week or two. You can usually treat any discomfort that persists after that time with over-the-counter pain relievers.

There is a good chance that you will feel very tired after a modified radical mastectomy. Try to take a break from some of your regular activities and rest during the two weeks following your surgery.

Depending on the size of your tumor and whether the cancer has spread to your lymph nodes, your doctor might recommend that you have radiation after modified radical mastectomy surgery to eliminate any remaining cancer cells.

Keep in mind, not all women can have a modified radical mastectomy, and there are many surgical options for breast cancer. Your doctor will decide which kind of surgery is best for you based on the size of the tumor, its stage (how far it has spread), and its grade (how aggressive it is). Your age and overall health will also be factored into the decision.

What Is Mastectomy?

Mastectomy is the removal of the whole breast. There are five different types of mastectomy: "simple" or "total" mastectomy, modified radical mastectomy, radical mastectomy, partial mastectomy, and subcutaneous (nipple-sparing) mastectomy.

"Simple" or "total" mastectomy

Simple or total mastectomy concentrates on the breast tissue itself:

• The surgeon removes the entire breast.
• The surgeon does not perform axillary lymph node dissection (removal of lymph nodes in the underarm area). Sometimes, however, lymph nodes are occasionally removed because they happen to be located within the breast tissue taken during surgery.
• No muscles are removed from beneath the breast.

Simple MastectomyLarger Version

Who usually gets simple or total mastectomy?

A simple or total mastectomy is appropriate for women with multiple or large areas of ductal carcinoma in situ (DCIS) and for women seeking prophylactic mastectomies — that is, breast removal in order to prevent any possibility of breast cancer occurring.

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Modified radical mastectomy

Modified radical mastectomy involves the removal of both breast tissue and lymph nodes:

• The surgeon removes the entire breast.
• Axillary lymph node dissection is performed, during which levels I and II of underarm lymph nodes are removed (B and C in illustration).
• No muscles are removed from beneath the breast.

Modified radical mastectomyLarger Version

Who usually gets a modified radical mastectomy?

Most people with invasive breast cancer who decide to have mastectomies will receive modified radical mastectomies so that the lymph nodes can be examined. Examining the lymph nodes helps to identify whether cancer cells may have spread beyond the breast.

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Radical mastectomy

Radical mastectomy is the most extensive type of mastectomy:

• The surgeon removes the entire breast.
• Levels I, II, and III of the underarm lymph nodes are removed (B, C, and D in illustration).
• The surgeon also removes the chest wall muscles under the breast.

Radical mastectomyLarger Version

Who usually gets a radical mastectomy?

Today, radical mastectomy is recommended only when the breast cancer has spread to the chest muscles under the breast. Although common in the past, radical mastectomy is now rarely performed because in most cases, modified radical mastectomy has proven to be just as effective and less disfiguring.

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Partial mastectomy

Partial mastectomy is the removal of the cancerous part of the breast tissue and some normal tissue around it. While lumpectomy is technically a form of partial mastectomy, more tissue is removed in partial mastectomy than in lumpectomy.

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Subcutaneous ("nipple-sparing") mastectomy

During subcutaneous ("nipple-sparing") mastectomy, all of the breast tissue is removed, but the nipple is left alone. Subcutaneous mastectomy is performed less often than simple or total mastectomy because more breast tissue is left behind afterwards that could later develop cancer. Some physicians have also reported that breast reconstruction after subcutaneous mastectomy can result in distortion and possibly numbness of the nipple. Because subcutaneous mastectomy is still an area of controversy among some physicians, your doctor may recommend simple or total mastectomy instead.

Sentinel Lymph Node Technique for Staging of Breast Cancer

Lymphatic mapping and sentinel lymphadenectomy is becoming an important surgical technique for assessing axillary status in breast cancer. In experienced hands, it can be successfully performed in >90% of cases. The morbidity of sentinel lymphadenectomy is minimal, considerably less than the 15%-20% rate of complications associated with axillary lymph node dissection. Moreover, excision of the sentinel node provides a specimen for focused histopathologic analysis and experimental studies using sensitive immunohistochemical techniques and even reverse transcriptase polymerase chain reaction, which may improve detection of axillary metastases. Intraoperative mapping of the lymphatic tract draining to the sentinel node may use vital blue dye and/or radioactive tracer. The rate of sentinel node detection exceeds 90% with either agent alone or in combination. Because definitive follow-up data are not yet available, intraoperative lymphatic mapping and sentinel lymphadenectomy should be considered an experimental staging adjunct rather than a therapeutic modality.

Axillary lymph node status is the most important prognostic indicator for patients with primary breast cancer [1, 2]. The prognostic significance of axillary nodal involvement also extends to the number of nodes involved [3]. Axillary lymphadenectomy (ALND) with histopathologic study of the axillary specimen remains the gold standard for detecting axillary nodal involvement and determining the number of nodes involved [4]. However, the low (<3%) rate of axillary recurrence in patients undergoing level I-II ALND [5-7] is achieved at the cost of significant morbidity, with an acute complication rate of 20%-30% and a chronic lymphedema rate as high as 20%-30% [8-12]. Therefore, routine ALND is controversial in breast cancer patients who have a low risk of axillary metastasis or who would receive adjuvant therapy regardless of axillary involvement. At present, there are no adequate noninvasive techniques for assessment of axillary status in patients with primary breast cancer. Physical exam carries a 29%-38% false negative rate, and radiographic methods (mammography, computed tomography, and positron emission tomography) have not achieved the level of accuracy on which to base clinical decisions [13-17]. Although complication rates may decrease by limiting the extent of axillary dissection, nondirected sampling of axillary nodes is associated with unacceptably high false negative rates: 40% for random axillary nodal sampling and 10%-15% for excision of level I nodes [18]. Recent introduction of intraoperative lymphatic mapping and sentinel lymphadenectomy (SLND) for primary breast cancer allows directed and accurate assessment of axillary involvement with minimal morbidity [19].

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Development of Breast SLND

The SLND technique was developed and first reported by Morton et al. [20] for clinical stage I cutaneous melanoma and has since been validated by independent investigators [21, 22]. This technique is based on the concept that the tumor-bearing status of the sentinel node, i.e., the first node in the regional nodal basin that drains a primary tumor, reflects the tumor status of the entire nodal basin. Our group adapted Morton's dye-directed SLND technique for use in primary breast cancer [19].

Our initial trial was conducted during the developmental phase of adapting SLND from a cutaneous tumor system (melanoma) to a parenchymal tumor system (breast cancer). Sentinel nodes were detected in 114 of 174 patients (65.5%) who underwent dye-directed SLND followed by ALND [19], and the sentinel node accurately reflected axillary tumor status in 109 of 114 SLND procedures (95.6%). The 59% rate of sentinel node detection in the first 87 patients increased to 72% in the remaining 87 patients; the detection rate reached 78% by the last 50 cases in this series. However, the technique and indications were evolving. All false negatives occurred in the first 87 cases; three were caused by mistaking blue-stained fat for a sentinel lymph node. During this phase of development, the optimal amount of dye needed and the interval from dye injection to dissection were determined.

In our subsequent study of 162 patients undergoing SLND followed by completion ALND [23], frozen section examination was performed to confirm the presence of nodal tissue in the SLND specimen and to prepare for the study, in which no further axillary dissection would be performed. Immunohistochemical study (IHC) of sentinel nodes that stained negative with hematoxylin and eosin (H&E) was also introduced to increase the rate of detecting metastases. The rate of axillary metastases was 42%, compared with 29.1% in a contemporaneous cohort of 134 patients undergoing ALND alone. Thus, the SLND technique in combination with IHC staining improved axillary staging of breast cancer patients.

We then examined the accuracy of the mature SLND technique in 107 patients with T1-T2 breast cancer who underwent SLND followed by completion ALND. SLND was successful in 100 patients (93.5%). There were no false negative results, and sentinel node status was 100% predictive of axillary tumor involvement [24]. Based on the results of this study, in 1995 we stopped performing completion ALND in patients whose sentinel nodes were free of tumor cells.

Although the sensitivity and accuracy of the SLND technique validate the sentinel node concept, we undertook an exhaustive IHC assessment of 1,087 nonsentinel nodes removed from 60 breast cancer patients who had no IHC evidence of tumor cells in multiple sections of their sentinel nodes [25]. These patients were identified from a cohort of 103 consecutive breast cancer patients undergoing SLND. We identified only one tumor-positive nonsentinel node, an error rate of 0.1% (1/1,087) and an axillary status staging error rate of 0.9% (1/103). This confirms the validity of the sentinel node hypothesis in breast cancer.

Although our SLND technique is based on dye-directed intraoperative mapping, other investigators have mapped lymphatic drainage using a hand-held gamma probe and a radioactive tracer. Krag et al. [26] first described probe-directed intraoperative mapping in breast cancer using Tc-99m sulfur colloid as the tracer material. Sentinel nodes were detected in 18 of 22 patients (82%). Subsequently, Veronesi et al. [27] reported probe-directed mapping using Tc-99m-labeled human serum albumin colloid in 163 consecutive breast cancer patients who underwent SLND followed by ALND. The sentinel node was identified in 160 patients (98.2%), and its tumor status matched that of the ALND specimen in 156 patients (97.5%). Recently, Borgstein et al. [28] reported their experience with probe-directed SLND using Tc-99m labeled colloidal albumin in T1-T2 breast cancer. The sentinel node was detected in 122 of 130 patients (94%), and the technique had a sensitivity of 98%, with a false negative rate of 1.7%.

Albertini et al. [29] combined dye-directed and probe-directed mapping in 62 patients with primary breast cancer. The rate of sentinel node detection was 73% with blue dye, increasing to 92% with the additional sentinel nodes detected by probe. Sensitivity was 100% and there were no false negatives. Barnwell et al. [30] recently reported their experience with this combination approach in 42 patients undergoing SLND followed by level I/II ALND. Sentinel nodes were detected in 38 patients (90%) and were 100% accurate in predicting the tumor status of the axilla. The average number of sentinel nodes excised in the study of Albertini et al. [29] (2.2 per basin) is similar to that reported by Giuliano et al. [24] using dye alone (1.6-1.8 per basin) and to that reported by Borgstein et al. [28] and Veronesi et al. [27] using the probe alone (1.2 per basin and 1.4 per basin, respectively). This similarity underlines the fact that SLND requires only a very small specimen for accurate assessment of the axilla. It can be successfully performed in a great majority of patients with dye and/or radioactive tracer.

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Technique

The sentinel node to be excised during SLND is identified intraoperatively by lymphatic mapping using a vital blue dye and/or a radioactive tracer. In either case, the technique can be done with local anesthesia and heavy sedation, or with light general anesthesia. For dye-directed lymphatic mapping and SLND, preoperative lymphoscintigraphy is recommended if the primary tumor is in the medial quadrants, to ascertain presence of drainage to the axilla. Rarely, tumor located in the medial quadrants may drain only to lymph nodes in the internal mammary chain. Also, tumor located in the inner upper quadrant may drain directly to level III nodes.

At the time of surgery, 3-5 ml of isosulfan blue dye (Lymphazurin^®) is injected into the breast parenchyma immediately adjacent to the breast mass laterally and below the subcutaneous fat, to avoid tattooing the overlying skin. If the primary tumor was excised previously, dye is injected into the wall of the biopsy cavity. If the primary tumor is not palpable, a needle inserted under mammographic guidance for tumor localization is used to inject the dye. Approximately 5 minutes after dye injection, a transverse incision is made just below the hair-bearing area in the axilla. Blunt dissection is performed to identify the dye-filled lymphatic tract. This tract is then followed proximally and distally until a blue-stained sentinel node is identified (Fig. 1⇓). If more than one dye-filled lymphatic tract is identified, each is followed. These tracts usually drain to the same sentinel node.

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Figure 1.

By following the dye-filled lymphatic tract (small arrow), the blue-stained sentinel node (large arrow) is identified.

Probe-directed mapping using a radioactive tracer is performed by injecting technetium-99m (Tc-99m) labeled sulfur colloid [26] or albumin colloid [27, 28] 2-24 h prior to operation. A lymphoscintigram is obtained preoperatively to determine the axillary drainage pattern from the primary tumor (Fig. 2⇓). At the time of surgery, a hand-held gamma-ray counter (Neoprobe^® or C-Trak^®) is held over the axilla to identify the area of greatest radioactivity in counts per second. A background count is established by measuring radioactivity over a neutral site. The skin is incised over the area of greatest radioactivity, and the probe is held over the incision to measure the in vivo radioactivity of axillary lymph nodes. The sentinel node is usually the node with the highest absolute count. After this node is excised, in vivo radioactivity of the axillary basin is reassessed. Some SLND investigators will continue to search for additional sentinel nodes if the absolute count of the basin still exceeds background.

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Figure 2.

Preoperative lymphoscintigram demonstrates the lymphatic drainage tract (small arrow) from primary tumor to the sentinel node (large arrow).

Because of the difference in the radioactive tracers used, there are no uniform criteria for identifying the sentinel node by its radioactive count. Krag et al. [26] used unfiltered sulfur colloid and defined a sentinel node as any node with radioactivity three times over the background and at least 15 counts per 10 seconds. Veronesi et al. [27] used albumin colloid and defined a sentinel node as the node with the highest radioactive count. Albertini et al. [29] used sulfur colloid and defined the sentinel node as the node with >10 times the radioactivity of neighboring nonsentinel nodes; these authors also searched for additional sentinel nodes if the basin count remained 150% higher than background. Despite nonuniform definitions of a sentinel node by radioactive count, probe-directed mapping has the advantage of detecting any “hidden” sentinel node with a count higher than background. In contrast, dye-directed mapping allows surgeons to visualize the sentinel node before its excision. The blue dye technique is especially helpful when the primary tumor is close to the lymph node basin, because the radioactivity of the primary can obscure counts in the lymph node basin (shine-through effect).

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Histopathologic Analysis of Sentinel Nodes

Because the SLND specimen contains only one or two lymph nodes, it can be routinely examined in multiple sections with IHC staining for low and intermediate molecular weight cytokeratin. This meticulous histopathologic assessment increases the sensitivity of detecting micrometastases. In our study, the 42% rate of axillary metastasis in 162 patients undergoing SLND followed by ALND was significantly (p < 0.03) higher than the 29.1% rate in 134 patients undergoing ALND alone [23]. The corresponding rates of axillary micrometastasis (≤2 mm) were 38.2% (26/68) and 10.3% (4/39). Eleven of the 26 micrometastases in the SLND group were identified by IHC staining after H&E stains were negative. Thus, the detailed examination of the sentinel node “upstaged” an additional 16% (11/68) of axillary lymph node basins.

Although the significance of axillary micrometastases has not been validated in a prospective fashion, several retrospective studies suggest that micrometastases are associated with poor outcome (Table 1⇓) [31-37]. The International (Ludwig) Breast Cancer Study Group used serial sectioning of axillary lymph nodes to identify micrometastases in 9% (83/921) of breast cancer patients whose nodes were tumor-free by routine histopathological examination [33]. Patients with micrometastases had lower rates of five-year disease-free survival (p = 0.0003) and overall survival (p = 0.002) than those whose nodes remained negative: 58% and 79%, respectively, versus 74% and 88%, respectively. Two subsequent large (n > 100) retrospective analyses also demonstrated the prognostic importance of identifying occult micrometastases when H&E stains are negative. De Mascarel et al. [35] used IHC to identify micrometastases in 50 of 218 patients (23%) whose ALND specimens stained negative for tumor cells with H&E. In patients with invasive ductal carcinoma, IHC-detected micrometastases were the most significant factor associated with recurrence (multivariate p -value = 0.011). Although IHC-detected micrometastases were not significant for survival in this subset of patients on univariate analysis (p = 0.07), they were significant on multivariate analysis (p = 0.027). Hainsworth et al. [36] identified occult metastases in 41 of 343 “node negative” patients (12%) whose nodal specimens were reexamined with IHC. The presence of occult metastases increased the five-year recurrence rate from 16% to 32%. A prospective study of the significance of IHC-detected occult metastases will be conducted by the American College of Surgeons.

Diverticulitis

Diverticulitis Overview

Diverticula are small pouches in the wall of the digestive tract. They occur when the inner layer of the digestive tract bulges through weak spots in the outer layer. (This is similar to what happens when an inner tube bulges through a tire.)

• Although these pouches can occur any place from the mouth to the anus, most occur in the large intestine (colon), especially the left (lower) portion of the colon just before the rectum.
• These marble-sized pouches usually occur where the blood vessels run through the intestinal wall.
• Individuals who have these pouches are said to have diverticulosis.
• Because this condition typically does not cause symptoms, most people are unaware that they have diverticulosis.

Picture of Diverticular Disease

Diverticulitis vs diverticulosis

Diverticulitis is inflammation of diverticula. Diverticulitis occurs when one or more of these pouches becomes inflamed or infected. Some people with diverticulosis become aware of the condition only when acute diverticulitis occurs.

Diverticulosis is a very common condition in the United States.

• Diverticulosis is mainly a condition of older people.
• A smal percentage of Americans over the age of 40 have diverticulosis. As we age, the condition becomes more prevalent. Over half of people older than 60 years of age develop the condition, and about two-thirds of individuals older than 80 years of age are believed to have diverticulosis.
• Only a few people with diverticulosis will develop diverticulitis.

Diverticulosis is more common in developed or industrialized countries.

• In places such as the United States, England, and Australia, where the typical diet is low in fiber and high in highly processed carbohydrates, diverticulosis is common. The current theory is that a low-fiber diet may cause increased incidence of diverticular disease.
• Diverticulosis first appeared in the United States in the early 1900s. This was about the same time when processed foods were first introduced into the U.S. diet.
• Diverticulosis is much less common in countries of Asia and Africa, where the typical diet is high in fiber.

Most people recover from diverticulitis without complications if they receive appropriate treatment. Diverticulitis can lead to some very serious conditions if it is not detected and treated promptly. To a great extent, diverticulosis and diverticulitis can be prevented by changes in lifestyle and habits.

Diverticulitis Causes

Diverticulosis is thought to be caused by increased pressure on the intestinal wall from inside the intestine.

• As the body ages, the outer layer of the intestinal wall thickens. This causes the open space inside the intestine to narrow. Stool (feces) moves more slowly through the colon, increasing the pressure.
• Hard stools, such as those produced by a diet low in fiber or slower stool "transit time" through the colon can further increase the pressure.
• Frequent, repeated straining during bowel movements also increases the pressure and contributes to the formation of diverticula.

Diverticulosis in developed countries is blamed largely on a diet low in fiber.

• Fiber is found in fruits and vegetables, whole grains, and legumes (dried beans, peas, and lentils).
• There are two types of fiber, soluble (dissolves in water) and insoluble.
• Soluble fiber forms a soft gel-like substance in the digestive tract.
• Insoluble fiber passes through the digestive tract nearly unchanged.
• Both are necessary to keep stool soft and moving easily through the digestive tract, which helps prevent constipation.
• This is how fiber prevents constipation.

Diverticulitis Symptoms

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Most people with diverticulosis have no symptoms. When symptoms do occur, they are usually mild and include the following:

• pain in the belly (abdomen),
• bloating,
• constipation (less often, diarrhea), and
• cramping.

These symptoms are nonspecific. This means that similar symptoms are seen in many different digestive disorders. They do not necessarily mean that a person has diverticulosis. If an individual has these symptoms, he or she should see a health care practitioner.

Diverticulitis is a more serious condition and causes symptoms in most people with the condition that include:

• pain in the abdomen, usually in the lower left side;
• bleeding, bright red or maroon blood may appear in the toilet, on the toilet paper, or in the stool. Bleeding is often mild and usually stops by itself; however, it can become severe;
• fever;
• nausea;
• vomiting;
• chills; and
• constipation (less often, diarrhea).

If diverticulitis is not treated promptly it can develop some very serious complications. A complication is suggested by any of the following symptoms:

• worsening abdominal pain;
• persistent fever;
• vomiting (no food or liquid can be tolerated);
• constipation for an extended period of time;
• burning or pain during urination; and
• bleeding from the rectum.

When to Seek Medical Care

If a person should see a health care practitioner if he or she has any of the following symptoms, which may indicate a serious condition:

• persistent abdominal pain, often in the lower-left area of the abdomen;
• persistent unexplained fevers;
• persistent diarrhea;
• persistent vomiting; or
• persistent or recurring urinary tract infection.

Any time a person has bleeding from the rectum, he or she should see a health care practitioner as soon as possible.

• Seek medical care even if the bleeding stops on its own.
• Bleeding may be a sign of diverticulitis or other serious diseases.
• If there is a lot of blood or a steady flow of blood, go to a hospital emergency department immediately.

The following symptoms suggest a complication and warrant an immediate visit to an emergency department:

• worsening abdominal pain;
• persistent fever with abdominal pain;
• vomiting so severe that food or liquids cannot be tolerated;
• swelling or distention of the abdomen;
• persistent constipation for an extended period of time; or
• severe pain or other symptoms that you had before when you had diverticulitis.

A person should not attempt to drive themselves to receive medical help, they should have someone else drive them, or call 911 for emergency medical transport. Calling for an ambulance often speeds the trip to the hospital when there is an emergency.

Diverticulitis Diagnosis

The health care practitioner will ask the patient questions about his or her symptoms, lifestyle and habits, and medical and surgical history.

• The physical exam will probably include a "digital rectal examination" in which a health care practitioner inserts a gloved finger into the rectum to try to find a cause for bleeding or pain.
• Blood tests may be performed to access signs of blood loss or infection, evaluate the function of the kidneys and liver, or to rule out other medical conditions that could be causing similar symptoms.
• X-rays of organs in the abdomen may be ordered to assist in identifying the cause of the patient's symptoms.
• CT scans are similar to an X-ray except they are able to visualize the organs better and often provide the health care practitioner with more useful information. One drawback with CT scans is that they are more expensive, and take longer to perform.
• A colonoscopy is a procedure performed using a flexible tube with a tiny camera at the end, called an endoscope. The endoscope is inserted into the rectum and further up into the colon. The endoscope provides a direct view of the inner lining of the colon and rectum. The procedure is relatively painless and usually takes 30 to 45 minutes. Patients may be given a sedative medication to relax during the procedure.
• A flexible sigmoidoscopy is a procedure performed with a flexible sigmoidoscope that has a tiny camera at the end of the sigmoidoscope. The patient lays on his or her left side while the instrument is inserted through the anus and advanced through the rectum and colon. This procedure is relatively painless and takes about five minutes.

Sometimes diverticulosis is discovered during a screening colonoscopy. The American Cancer Society and the United States Multi-Society Task Force on Colorectal Cancer recommend colonoscopies every 10 years for people older than 50 years to detect early signs of colon cancer. If an individual's family medical history includes a close relative diagnosed with colon cancer, they may need to begin screening at an earlier age. Consult a gastroenterologist for guidelines.

Diverticulitis Self-Care at Home

These measures may help and prevent new diverticula from forming.

• Eat a high-fiber diet. High-fiber foods include fruits, vegetables, whole grains, and dried beans, peas, and lentils. These foods contain elements that your body cannot digest and are passed through your colon.
• Drink plenty of fluids to help keep stools soft and prevent constipation.
• Get plenty of physical activity to keep bowels functioning properly.

Diverticulitis Medical Treatment

Diverticulosis with symptoms is usually treated as follows. This therapy is designed to soften stools and help them pass faster, which removes the conditions that cause diverticula in the first place.

• High-fiber diet: Some health care practitioners recommend a fiber supplement to prevent constipation.
• Clear fluids
• Mild pain medications

Treatment for diverticulitis depends on the severity of the condition.

• Simple cases can be treated by a health care practitioner at his or her office.
• Treatment for uncomplicated cases usually consists of antibiotics and bowel rest. This usually involves two to three days of bowel rest, taking in only clear fluids (no food at all), so the colon may heal without having to work.
• Complicated cases typically involve severe pain, fever, or bleeding. If an individual has any of these symptoms, he or she will probably be admitted to the hospital. Treatment consists of IV antibiotics, bowel rest, and possibly surgery.

Diverticulitis Surgery

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If diverticulitis attacks are frequent or severe, the doctor may suggest surgery to remove a part of the patient's colon.

• As with any surgery, there are risks that the patient should discuss with his or her physician.
• Sometimes the operation requires at least two separate surgeries on different occasions.

Diverticulitis Diet

A high-fiber diet is the mainstay of diverticulosis and diverticulitis prevention.

• Starting a high-fiber diet may not make the diverticula a person has go away, but it will decrease the risk of complications and the accompanying symptoms.
• Foods high in fiber include whole-grain cereals and breads, fruits (apples, berries, peaches, pears), vegetables (squash, broccoli, cabbage, and spinach), and dried beans, peas, and lentils.
• Drinking plenty of fluids will also help the stool stay soft and pass quickly, decreasing the risk for diverticulosis.

There has been debate over whether those with diverticulosis or diverticulitis should be advised to avoid foods such as nuts, corn, and popcorn. A 2008 study published in the The Journal of the American Medical Association found these foods may actually lower risk of the condition because of their high fiber content. Consult a health care practitioner for the dietary recommendations.

Diverticulitis Follow-Up

Eating a high-fiber diet will not only decrease a person's chance of getting diverticulitis; it will benefit health in other ways such as by lowering the risk of colon cancer and possibly heart disease.

In a significant number of people, diverticulitis recurs after it has been treated. The second episode may be worse than the first. See a health care practitioner at the first sign of recurring symptoms.

Diverticulitis Prevention

As mentioned previously, a high-fiber diet is the mainstay of diverticulosis and diverticulitis prevention.

Diverticulitis Prognosis

Most people recover fully after treatment. If not treated promptly, however, diverticulitis can lead to the following more serious conditions:

• Perforation: A hole in the intestine caused when the diverticular pouch bursts because of increased pressure and infection within the intestine.
• Peritonitis: A more serious infection of the abdominal cavity that often occurs after perforation, when the contents of the intestine leak out into the abdominal cavity (peritoneum) outside of the intestine.
• Abscess: A pocket of infection that is very difficult to cure with antibiotics.
• Fistula: An abnormal connection between the colon and another organ that occurs when the colon damaged by infection comes in contact with another tissue, such as the bladder, the small intestine, or the inside of the abdominal wall, and sticks to it. Fecal material from the colon can then get into the other tissue. This often causes a severe infection. If fecal material gets into the bladder, for example, the resulting urinary tract infection can become recurrent and very difficult to cure.
• Blockage or obstruction of the intestine
• Bleeding in the intestine

Individuals younger than 40 years of age who have depressed immune systems from medications or other illnesses have a greater chance of having complications and having to undergo surgery.

Approximately one-half of people who have diverticulitis will have a relapse within seven years after the condition is treated and in remission.

Of the people who are admitted to a hospital for diverticulitis, some develop complications that require surger

Topic Overview

What is diverticulitis?

Diverticulosis happens when pouches (diverticula) form in the wall of the colon. If these pouches get inflamed or infected, it is called diverticulitis. Diverticulitis can be very painful.

What causes diverticulitis?

Doctors aren't sure what causes diverticula in the colon (diverticulosis). But they think that a low-fiber diet may play a role. Without fiber to add bulk to the stool, the colon has to work harder than normal to push the stool forward. The pressure from this may cause pouches to form in weak spots along the colon.

Diverticulitis happens when feces get trapped in the pouches (diverticula). This allows bacteria to grow in the pouches. This can lead to inflammation or infection.

What are the symptoms?

Symptoms of diverticulitis may last from a few hours to a week or more. Symptoms include:

• Belly pain, usually in the lower left side, that is sometimes worse when you move. This is the most common symptom.
• Fever and chills.
• Bloating and gas.
• Diarrhea or constipation.
• Nausea and sometimes vomiting.
• Not feeling like eating.

How is diverticulitis diagnosed?

Your doctor will ask about your symptoms and will examine you. He or she may do tests to see if you have an infection or to make sure that you don't have other problems. Tests may include:

• Blood tests, such as a complete blood count (CBC).
• Other tests, such as an X-ray or a CT scan.

How is it treated?

The treatment you need depends on how bad your symptoms are. You may need to have only liquids at first, and then return to solid food when you start feeling better. Your doctor will give you medicines for pain and antibiotics. Take the antibiotics as directed. Do not stop taking them just because you feel better.

For mild cramps and belly pain:

• Use a heating pad, set on low, on your belly.
• Relax. For example, try meditation or slow, deep breathing in a quiet room.
• Take medicine, such as acetaminophen (Tylenol, for example).

You may need surgery only if diverticulitis doesn't get better with other treatment, or if you have problems such as long-lasting (chronic) pain, a bowel obstruction, a fistula, or a pocket of infection (abscess).

How can you prevent diverticulitis?

You may be able to prevent diverticulitis if you drink plenty of water, get regular exercise, and eat a high-fiber diet. A high-fiber diet includes whole grains, fresh fruits, and vegetables.

y.

Diverticular Disease

Diverticulosis of the colon is a common condition that afflicts about 50 percent of Americans by age 60 and nearly all by age 80. Only a small percentage of those with diverticulosis have symptoms, and even fewer will ever require surgery.

What is Diverticulosis/ Diverticulitis?  

Diverticula are pockets that develop in the colon wall, usually in the sigmoid or left
colon, but may involve the entire colon. Diverticulosis describes the presence of these pockets. Diverticulitis describes inflammation or complications of these pockets. 

What are the symptoms of diverticular disease?  

Uncomplicated diverticular disease is usually not associated with symptoms. Symptoms are related to complications of diverticular disease including diverticulits and bleeding. Diverticular disease is a common cause of significant bleeding from the colon.  

Diverticulitis - an infection of the diverticula - may cause one or more of the following symptoms: pain in the abdomen, chills, fever and change in bowel habits. More intense symptoms are associated with serious complications such as perforation (rupture), abscess or fistula formation (an abnormal connection between the colon and another organ or the skin).

What is the cause of diverticular disease?  

The cause of diverticulosis and diverticulitis is not precisely known, but it is more common for people with a low fiber diet. It is thought that a low-fiber diet over the years creates increased colon pressure and results in pockets or diverticula.

How is diverticular disease treated?  

Increasing the amount of dietary fiber (grains, legumes, vegetables, etc.) - and sometimes restricting certain foods reduces the pressure in the colon and may decrease the risk of complications due to diverticular disease.  

Diverticulitis requires different management. Mild cases may be managed with oral antibiotics, dietary restrictions and possibly stool softeners. More severe cases require hospitalization with intravenous antibiotics and dietary restraints. Most acute attacks can be relieved with such methods.

When is surgery necessary?  

Surgery is reserved for patients with recurrent episodes of diverticulitis, complications or severe attacks when there's little or no response to medication. Surgery may also be required in individuals with a single episode of severe bleeding from diverticulosis or with recurrent episodes of bleeding.  

Surgical treatment for diverticulitis removes the diseased part of the colon, most commonly, the left or sigmoid colon. Often the colon is hooked up or "anastomosed" again to the rectum. Complete recovery can be expected. Normal bowel function usually resumes in about three weeks. In emergency surgeries, patients may require a temporary colostomy bag. Patients are encouraged to seek medical attention for abdominal symptoms early to help avoid complications.  

What is a colon and rectal surgeon?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

LAPAROSCOPIC CHOLECYSTECTOMY

What is a laparoscopic cholecystectomy? Laparoscopic cholecystectomy is a procedure in which the gallbladder is removed by laparoscopic techniques. Laparoscopic surgery also referred to as minimally invasive surgery describes the performance of surgical procedures with the assistance of a video camera and several thin instruments. During a laparoscopic surgical procedure, small incisions of up to half an inch are made and plastic tubes called ports are placed through these incisions. The camera and the instruments are then introduced through the ports which allow access to the inside of the patient. The camera transmits an image of the organs inside the abdomen onto a television monitor.The surgeon is not able to see directly into the patient without the traditional large incision. The video camera becomes a surgeon’s eyes in laparoscopy surgery, since the surgeon uses the image from the video camera positioned inside the patient’s body to perform the procedure. Benefits of minimally invasive or laparoscopic procedures include less post operative discomfort since the incisions are much smaller, quicker recovery times, shorter hospital stays, earlier return to full activities and much smaller scars. Furthermore, there may be less internal scarring when the procedures are performed in a minimally invasive fashion compared to standard open surgery. How safe is laparoscopic gallbladder surgery? Laparoscopic cholecystectomy is a very safe operation. The overall complication rate is less than 2%. The complication rate for laparoscopic gallbladder surgery is similar to the complication rate for traditional open gallbladder surgery when performed by a properly trained surgeon. How is laparoscopic cholecystectomy performed? Many thousands of laparoscopic cholecystectomy have been performed in the USA and this operation has an excellent safety record. Some of the important steps in the operation are as follows: General anesthesia is utilized, so the patient is asleep throughout the procedure. An incision that is approximately half an inch is made around the umbilicus ( belly button), three other quarter to half inch incisions are made for a total of four incisions. Four narrow tubes called laparoscopic ports are placed through the tiny incisions for the laparoscopic camera and instruments. A laparoscope (which is a long thin round instrument with a video lens at its tip) is inserted through the belly button port and connected to a special camera. The laparoscope provides the surgeon with a magnified view of the patient's internal organs on a television screen. Long specially designed instruments are inserted through the other three ports that allow your surgeon to delicately separate the gallbladder from its attachments to the liver and the bile duct and then remove it through one of the ports from the abdomen. Your surgeon may occasionally perform an X-ray, called a cholangiogram, to exam for stones in the bile duct. After the gallbladder is removed from the abdomen then the small incisions are closed What happens if at surgery the surgeon cannot complete the operation with laparoscopic techniques In a small number of patients if excessive scarring is present or the anatomy of the structures is not clear then for safety reasons the surgeon may decide too convert the operation to an open surgical operation through a traditional large surgical incision. Less than 5% of all laparoscopic cholecystectomy procedures are converted to open procedures. The decision to convert to an open operation is strictly based on patient safety. Factors that may increase the risk of converting to the "open" procedure include obesity, a history of prior abdominal surgery causing dense scar tissue, acute cholecystitis or bleeding problems during the operation. What are the risks of laparoscopic gallbladder surgery? Complications of a laparoscopic cholecystectomy are infrequent and the vast majority of laparoscopic gallbladder patients recover and quickly return to normal activities. Some of the complications that can occur include bleeding, infection, leakage of bile in the abdomen, pneumonia, blood clots, or heart problems. Surgical injury to an adjacent structures such as the common bile duct, duodenum or the small intestine may occur rarely and may require another surgical procedure to repair it. If the gallbladder is accidentally or deliberately opened during the procedure stones may fall out of the gallbladder and in to the abdomen that may give rise to later scarring. How long will you be in the hospital? Once a diet is tolerated, patients leave the hospital. Most patients go home the next day after a laparoscopic cholecystectomy. Some may even go home the same day the operation is performed. This compares with a five day stay following the open cholecystectomy procedure. What is the recovery period and how soon can you go back to work? Patients will probably be able to get back to normal activities within a week's time, including driving, walking up stairs, light lifting and work. Activity is dependent on how the patient feels. Walking is encouraged. Patients can remove the dressings and shower the day after the operation. In general, recovery should be progressive, once the patient is at home. Most patients are fully recovered and may go back to work after seven to ten days. Often, this depends on the nature of your job since patients who perform manual labor or heavy lifting may require two to four weeks of recovery. What should you be concerned about after going home? The development of fever, yellow skin or eyes, worsening abdominal pain, distention, persistent nausea or vomiting, or drainage from the incision are indications that a complication may have occurred. You should contact your surgeon under these circumstances.

Doctors hopeful of new breast cancer treatment

A world-first clinical trial to test new imaging technology that can scan tumours during breast cancer surgery has been launched at Guy's and St Thomas' NHS Foundation Trust in collaboration with King's College London

In a world-first clinical trial, Guy's and St Thomas' NHS Foundation Trust will begin test new imaging technology that can scan tumours during breast cancer surgery.

Every year in the UK 50,000-55,000 women are diagnosed with breast cancer. 70 per cent of those women will go on to require surgery via lumpectomy (removal of the cancerous lump), while 30 per cent require a mastectomy (the complete removal of the breast tissue).

While surgeons do their best to ensure the complete removal of cancerous breast tissue, up to 25 per cent of women who undergo a lumpectomy will require further surgery to remove more of the cancerous breast tissue.

That's due to the microscopic tumor cells left behind, which takes pathologists a week to detect.

"This places enormous burden on the patient who has to come back in for a second operation, potentially delay the next stage of their treatment," explains consultant surgeon, Professor Arnie Purushothamand. "You can imagine the burden of anxiety that is placed upon these patients."

Childhood Cancer Awareness

Families, caregivers, charities and research groups across the United States observe September as Childhood Cancer Awareness Month. In the U.S., 15,780 children under the age of 21 are diagnosed with cancer every year; approximately 1/4 of them will not survive the disease. A diagnosis turns the lives of the entire family upside down. The objective of Childhood Cancer Awareness Month is to put a spotlight on the types of cancer that largely affect children, survivorship issues, and - importantly - to help raise funds for research and family support.

Photo Credit: Marie-Dominique Verdier Awareness Month Kits on ACCO e-Store We have combined several of our popular store items into special awareness kits for the month of September. Kits include gold ribbon lapel pins, gold ribbon stickers, car magnets, and more. Click the links below to visit our e-store. Small Awareness Kit Medium Awareness Kit Large Awareness Kit

Childhood Cancer Awareness Month 2014 ACCO unites childhood cancer advocates across the country by highlighting individual stories through our Gold Ribbon Heroes Program and by registering and facilitating awareness events and fundraisers at schools and businesses. September is a time to commit to raising childhood cancer awareness all year. Pledge to bring awareness to your community, and choose an event option below! Nominate September Gold Ribbon Heroes Gold Ribbon Heroes are individuals who have made a positive impact on the lives of others. This includes patients, parents, hospital staff, volunteers, survivors, siblings, and more.  We want to recognize the impact they have made, and we hope you will share their stories to inspire others. Nominate your hero HERE. Host or Register Awareness Events We aim to register as many childhood cancer awareness events as possible during September. Of course, we would love to see many events in September, but we understand that many school and business calendars may not be able to accomodate additional events until later in the year. If this applies to your school or business, we urge you to commit to hosting an event, even if it cannot be held in September. Children with cancer need our support year-round! PJammin for Kids with Cancer Participants pay a minimum of $1 to wear pajamas in honor of kids with cancer. This is a great program for schools! Go Gold Participants plan and host a gold-themed event to raise awareness of the symbol for childhood cancer. This is a fun project for groups, businesses, and churches. These event choices offer enough ease and flexibility for anyone to join in this important initiative. Your participation will help create aware, supportive communitities for families who face this terrible diagnosis, and all donations will support the creation and implementation of support programs and materials. Participants have 2 different options (see below) to help plan and host their events. ACCO will provide fundraising consultation, if needed, and we will also provide gold ribbon stickers and free flyers for event promotion.

 

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Proclamations for Release - National Childhood Cancer Awareness Month

September 2012  NATIONAL CHILDHOOD CANCER AWARENESS MONTH, 2012 BY THE PRESIDENT OF THE UNITED STATES OF AMERICA A PROCLAMATION   Every year, thousands of children across America are diagnosed with cancer    an often life threatening illness that remains the leading cause of death by disease for children under the age of 15.  The causes of pediatric cancer are still largely unknown, and though new discoveries are resulting in new treatments, this heartbreaking disease continues to scar families and communities in ways that may never fully heal.  This month, we remember the young lives taken too soon, stand with the families facing childhood cancer today, and rededicate ourselves to combating this terrible illness.   While much remains to be done, our Nation has come far in the fight to understand, treat, and control childhood cancer.  Thanks to ongoing advances in research and treatment, the 5 year survival rate for all childhood cancers has climbed from less than 50 percent to 80 percent over the past several decades.  Researchers around the world continue to pioneer new therapies and explore the root causes of the disease, driving progress that could reveal cures or improved outcomes for patients.  But despite the gains we have made, help still does not come soon enough for many of our sons and daughters, and too many families suffer pain and devastating loss.   My Administration will continue to support families battling pediatric cancer and work to ease the burdens they face.  Under the Affordable Care Act, insurance companies can no longer deny health coverage to children because of pre existing conditions, including cancer, nor can they drop coverage because a child is diagnosed with cancer.  The law also bans insurers from placing a lifetime dollar limit on the amount of coverage they provide, giving families peace of mind that their coverage will be there when they need it most.  And as we work to ensure all Americans have access to affordable health care, my Administration will continue to invest in the cutting edge cancer research that paves the way for tomorrow's breakthroughs.   This month, we pay tribute to the families, friends, professionals, and communities who lend their strength to children fighting pediatric cancer.  May their courage and commitment continue to move us toward new cures, healthier outcomes, and a brighter future for America's youth.   NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim September 2012 as National Childhood Cancer Awareness Month.  I encourage all Americans to join me in reaffirming our commitment to fighting childhood cancer.   IN WITNESS WHEREOF, I have hereunto set my hand this thirty first day of August, in the year of our Lord two thousand twelve, and of the Independence of the United States of America the two hundred and thirty-seventh.   BARACK OBAMA

September 2011    September 2010

Senate Passes Allard-Clinton 'National Childhood Cancer Awareness Day' Resolution
May 23, 2008

WASHINGTON, D.C.– September 13, 2008 will now be recognized as "National Childhood Cancer Awareness Day" as a result of a Senate resolution introduced by U.S. Senators Wayne Allard (R-Colo.) and Hillary Rodham Clinton (D-NY).

 "Never before in history has the dream of eliminating childhood cancer been so attainable, yet seemed so elusive," said Senator Allard. "We live in a nation where the effectiveness of treatments and technology offer hope to children who dream of a bright future. Each case of childhood cancer is a very personal tragedy that can strike any family with children, at anytime, anywhere. In setting aside September 13th to recognize this battle on cancer, we continue of our efforts to draw attention to the victims of childhood cancer and the great work of the families and organizations who continue the fight."

 "We have made tremendous strides in the fight against childhood cancer, but far too many children still suffer and lose their lives to this illness. The more we know as a nation the better able we will be to prevent and treat the disease and help those who are battling and surviving pediatric cancers.  National Childhood Cancer Awareness Day is an opportunity to reach out to all Americans with the facts about childhood cancer, and this day will be an important symbol of our commitment on all days to find a cure," said Senator Clinton.

 Childhood cancer is the number one disease killer and the second overall leading cause of death of children in the United States. More than 10,000 children under the age of 15 in the United States are diagnosed with cancer annually.

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