2019, Limestone College, Silvio's review: "Purchase cheap Calcitriol - Quality Calcitriol online no RX".
Nonetheless buy calcitriol medications during pregnancy, the laparoscopic further studies being useful adjuncts in atypical cases discount 0.25mcg calcitriol mastercard medicine qhs. Generally buy 0.25mcg calcitriol visa medicine plies, both laparoscopic and stricture secondary to Crohn’s disease, Meckel’s diverticu- open appendectomy can be performed safely in the setting of lectomy, ileostomy, and appendectomy can be safely per- acute appendicitis; the choice of approach should be formed when the above principles are followed. Both open and laparoscopic are described in the chap- tify complications of appendicitis require tailored care. For patients with contained References perforation, the initial therapy is nonoperative. Barrier agents for adhesion spectrum antibiotics and supportive therapy are accompa- prevention after gynaecological surgery. Cochrane Database Syst nied by percutaneous drainage of any deﬁned abscess to Rev. Review article: the evidence base for interventions used tive in 95 % of patients (Oliak et al. Current management of small-bowel patients who are treated successfully, interval appendectomy obstruction. This practice has recently been called into abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter question and evaluated in several large, retrospective stud- study. Digestive tract surgery: citis is similar to the risk of an initial episode and that a text and atlas. Improving outcomes after laparoscopic appendectomy: a population-based, 12-year trend tions (Kaminski et al. An ﬁndings include inﬂammatory bowel disease or an appendi- epidemiologic population-based study. Laparoscopic versus open surgery found to have Crohn’s disease at operation, an appendec- for small bowel Crohn’s disease. Strictureplasty for Crohn’s disease with multiple In summary, multiple concepts must be followed for suc- long strictures. Routine interval mosis for benign, malignant, or traumatic disease, an enter- appendectomy is not justiﬁed after initial nonoperative treatment of olysis for small bowel obstruction, a stricturoplasty for a acute appendicitis. Primary cancers of the small perforated appendicitis without periappendiceal mass. Laparoscopic surgery for Crohn’s disease: a meta- Peyrin-Biroulet L, Deltenre P, Ardizzone S, et al. Laparoscopic compared with conventional treat- surgery for suspected appendicitis. Chassin† Indications Operative Strategy Tumor Open Versus Laparoscopic Technique Trauma Strangulation As with other abdominal procedures, laparoscopic techniques Perforation have been successfully applied to small bowel resection and Crohn’s enteritis with complications anastomosis. This chapter details basic principles essential for Ischemic enteritis success with either approach and stresses safe performance of small bowel anastomoses (sutured or stapled). Preoperative Preparation Nasogastric intubation in selected cases (obstruction, Successful Bowel Anastomosis Requirements perforation) Perioperative antibiotics 1. Determine this by noting pulsatile ﬂow after dividing a terminal arterial branch in the region where the bowel is to be transected. There should be no hema- Pitfalls and Danger Points toma near the anastomosis, as it could impair circulation. There Small bowel anastomosis is generally safe unless the blood should be no fat or other tissue between the two bowel supply is impaired or advanced peritoneal sepsis is present. The seromuscular suture must catch When a small bowel anastomosis fails because of technical the submucosa, where most of the tensile strength of the errors, the leak almost invariably occurs at the mesenteric intestine is situated. Optimal healing of an anastomosis border, where the serosa has not been adequately cleared of requires serosa-to-serosa approximation. This is the point at which several terminal blood vessels and accompanying fat are dissected from the bowel wall to provide visibility for accurate seromuscular suture placement. Clear fat and blood vessels from a 1-cm-wide area of serosa around the circumference of an anastomo- sis. Remember to allow for some degree of fore- shortening if postoperative distension occurs. Force must not be excessive when Contraindications to Anastomosis tying the anastomotic sutures, as it would result in stran- gulation of tissue. If the suture should inadvertently have Because of the excellent blood supply and substantial sub- been placed through the full thickness of the bowel and mucosal strength of the small bowel, anastomoses are often into the lumen, the strangulated tissue will cause a leak. When manipulat- indications to a primary small bowel anastomosis are perito- ing the ends of the bowel to be anastomosed, there must be neal sepsis, a questionable blood supply, or a patient whose no excessive force. If the imprint of forceps teeth is visible condition on the operating table is precarious. In these cases on the serosa after the forceps have been removed, the sur- both ends of the divided small bowel may be brought to the geon obviously compressed the tissue with too much force. One must learn the pitfalls (technical and conceptual) before constructing stapled intestinal Findings anastomoses. Study the strategy of avoiding the compli- Extent of resection cations of surgical stapling (see Chap. One must avoid the common errors jejunum) seen among neophytes learning the art of anastomotic Length of remaining bowel suturing: Do not insert the outer layer of seromuscular sutures with the collapsed bowel resting on a ﬂat surface. An even Operative Technique worse error consists in putting the left index ﬁnger under- neath the back of the anastomosis while inserting the ante- Small Bowel Anastomosis by Suturing rior seromuscular sutures. Both errors make it possible to pass the seromuscular suture through the bowel lumen and Incision catch a portion of the posterior wall. When the sutures are Use a midline vertical incision for the best exposure of the tied, an obstruction is created. To prevent this complication, simply have Division of Mesentery the assistant grasp the tails of the anastomotic sutures that have already been tied. Skyward traction on these sutures Expose the segment of intestine to be resected by laying it keeps the lumen of the anastomosis open while the sur- ﬂat on a moist gauze pad on the abdominal wall. Apply stretches the bowel wall, so it becomes relatively thin, medium-size hemostats in pairs to the intervening tissue. After the wedge of mesentery has been completely freed, distal , should be loosely placed in the operative ﬁeld. After the ﬁrst seromuscular bite has been taken, the nee- Apply noncrushing intestinal clamps proximally and distally dle is ready to be reinserted into the wall of the opposite to prevent spillage of intestinal contents. At this time it is often helpful to use eased segment of intestine by scalpel division. Elevation relaxes this segment of the Open Two-Layer Anastomosis bowel and permits the suture to catch a substantial bite of Considerable manipulative trauma to the bowel wall can be tissue, including the submucosa. Each bite should encom- avoided if the anterior seromuscular layer of sutures is the pass about 4–5 mm of tissue. First, use 4-0 silk on an atraumatic 43 Small Bowel Resection and Anastomosis 397 needle, and insert a seromuscular suture on the antimesen- and 43.
Apply caudad traction operative staging and careful dissection at the point where to the esophagus via the Penrose drain and free up the lower the azygos vein crosses the esophagus order calcitriol 0.25 mcg line 8h9 treatment. If the tumor can be reached by digital palpation generic calcitriol 0.25mcg mastercard medicine 5513, ascertain that it is not ﬁxed to the aorta or vertebral column order calcitriol 0.25mcg with mastercard symptoms vitamin b12 deficiency. If it is ﬁxed, transhiatal esophagectomy Documentation Basics without thoracotomy is contraindicated. If not, expose the gastric cardia and then carefully divide and ligate each of the Coding for esophageal procedures is complex. In clamps leaving 3–5 cm of omentum attached to the right gas- general, it is important to document: troepiploic arcade to avoid injury to the gastroepiploic artery. Elevate the greater curvature of the stomach in a cephalad direction and identify the origin of the left gastric artery. Cover the abdominal incision with sterile and insert bilateral intravenous catheters and one intra- towels and start the neck operation. If a central venous pressure or a Swan- Cervical Dissection Ganz catheter is to be used, insert it into the right internal jugular vein, as the left side of the neck is preserved for the Expose and mobilize the cervical esophagus as described in esophagogastric anastomosis. Encircle the esophagus with a Penrose drain and gist use a standard endotracheal tube of standard length that apply cephalad traction. If the membranous trachea is inad- aspect of the ﬁngers facing the esophagus to dissect the vertently lacerated, the anesthesiologist can then advance the esophagus away gently from the overlying trachea and the tip of the endotracheal tube into the left main bronchus. With this dissection, the index the balloon is inﬂated, this maneuver enables the anesthesi- ﬁnger can reach down almost to the carina of the trachea. Attach a self-retaining Thompson, Omni, or similar retractor to the operating table Wear a headlamp for this phase of the operation. Enlarge 16 Transhiatal Esophagectomy 165 the hiatal opening by incising the diaphragm with electro- cautery in an anterior direction through the middle of the central tendon, dividing and ligating the transverse phrenic vein during this step. If necessary, insert a ﬂat malleable retractor behind the heart and elevate gently. Determine that they are ﬂexible and mobile and that there are no points of tumor invasion that would make resection without thoracotomy inadvisable. Before embarking on further dissection, pass a 28F Argyle Saratoga suction catheter into the neck incision and then down into the lower mediastinum to facilitate evacuation of blood from the surgical ﬁeld. Despite the limited exposure allowed by the transhiatal approach, the transhiatal esophagectomy is neither a blind nor a crude operation. Dissection of the esophagus from the diaphragm to the arch of the aorta is performed under direct vision. Exposure can be enhanced by inserting long, narrow retractors along the lateral aspects of the hiatal aperture. Many of the vascular attachments to the esophagus can be divided and occluded by hemostatic clips or ligatures. When dissecting the esophagus in the mediastinum, make no spe- cial effort to excise any pleura or lymph nodes. The strategy of the operation is to separate the surrounding anatomy from the esophageal tube as efﬁciently as possible. When dissect- ing the esophagus along its posterior surface, keep the hand ﬂat against the vertebral column. After the esophagus has been removed from the mediastinum, and before the stomach is brought into the chest, examine the pleura visually and by palpation. If a tear has occurred, insert an appropriate chest tube to prevent a postoperative tension pneumothorax. After the lower esophagus has been mobilized, insert a small sponge on a long sponge holder (“sponge on a stick”) along the prevertebral fascia in the neck behind the esopha- gus while the other hand is placed behind the esophagus in the mediastinum (Fig. When the sponge-stick meets the hand, the posterior dissection of the esophagus has been completed. With the assistant exerting traction in a caudal direction on the Penrose trachea – left main stem bronchus. After this has been drain encircling the esophagogastric junction, place the accomplished, there remain lateral attachments to be dis- hand, palm down, on the anterior surface of the esophagus rupted before the esophagus is freed. Again retract the upper and with ﬁnger dissection free the esophagus from overlying esophagus in a cephalad direction and separate the esopha- pericardium and carina. With the other hand, insert one or gus from these attachments until the upper 8 cm of thoracic two ﬁngers, volar surface down, over the anterior face of the esophagus is freed circumferentially. Now insert the hand esophagus in the neck while cephalad traction is being into the hiatus and slide upward along the anterior esophagus applied to the Penrose drain encircling the cervical esophagus. Trap the esophagus against the ver- attachments between the esophagus and the membranous tebral column between the index and middle ﬁngers. Chassin esophagogastric junction and note where the second or third branch down of the left gastric artery enters the lesser curvature. At this point, apply the linear cutting stapler and aim it in a cephalad direction toward the cardia. Sequentially reapply and ﬁre the stapler until the lesser curvature has been amputated, leaving about 6–8 cm width of cardia intact at the gastric tip (Fig. Deliver 7–8 cm of thoracic esophagus into the neck and transect the esophagus with a linear cutting surgical stapler. This maneuver provides a few centimeters of extra esopha- gus, allowing the option of selecting the best length when the anastomosis is performed. This drain with its two identifying hemostats is later used to draw the stomach up through the posterior mediastinum into the neck. If a laceration is encountered, insert a 32F chest tube into the chest cavity on the side of the laceration, in the midaxillary line. Then insert moist gauze packing into the mediastinum to help achieve hemostasis while the stom- ach is being prepared. Exteriorize the stomach and attached esophagus by spreading it out along the patient’s anterior chest wall. Because the blood supply to the lesser curvature subse- quent to ligation of the left gastric artery is poor (Akiyama), the lesser curvature is excised, converting the stomach into a tubular structure (Fig. Now invert the entire should be located 3–5 cm down from the apex of the gastric staple line by means of a continuous 4-0 Prolene Lembert tube and above the level of the clavicle. Remove the identifying hemostat from the previ- back into the neck so it rests on the anterior wall of the gastric ously positioned Penrose drain that was brought down from tube. Make an incision in the anterior wall of the gastric tube the neck into the mediastinum. Suture this Penrose drain to in a vertical direction, the length being appropriate to the the most cephalad point of the gastric cardia using 3-0 silk diameter of the elliptical esophageal oriﬁce, which is approxi- sutures. Place gentle Be certain that the esophagus and stomach are positioned cephalad traction on the proximal end of the Penrose drain such that there is no tension on the suture line. This stitch passes through the muscle layer of the and into the posterior mediastinum until the stomach has esophagus and then enters the cephalad margin of the gastric been manipulated into the neck. To avoid the possibility of incision 4 mm above the incision, entering the lumen of the gastric torsion, be certain that the staple line along the stomach. When tying these sutures, make the knot just tight lesser curvature is located to the patient’s right and the enough to afford approximation, not strangulation. The long-tailed suture second stitch through the left lateral wall of the esophagus at the junction of the Penrose drain and the gastric cardia into the lumen, again catching at least 4 mm of mucosa, and identify the medial aspect of the gastric tube.
Because the mesh absorbs buy calcitriol line treatments, subsequent incisional full-thickness defects of the abdominal wall with retention of hernia formation is inevitable 0.25 mcg calcitriol with amex medications similar to gabapentin, and a delayed repair is needed an excellent blood supply to the ﬂap quality 0.25mcg calcitriol medicine quest. The tensor fasciae latae when the patient has recovered from the initial problem and muscle is one example of such a myocutaneous ﬂap that can sufﬁcient time (usually at least 6 months) has elapsed for the be used to bridge defects in the abdomen. Absorbable mesh is not suitable for permanent repair of ventral hernias as described in this chapter and will not be discussed further. Separation of Components Monoﬁlament nonabsorbable meshes from different man- ufacturers vary in chemical composition, stiffness (resis- Separation of components was originally described by tance to bending), and degree of stretch. As mentioned Ramirez as a way to obtain autologous tissue closure of earlier, erosion into bowel and dense adhesion formation moderate-sized abdominal wall defects with preservation of have been problems with these prosthetic materials. Because been further developed that facilitate closure of even large the mesh is composed of monoﬁlament ﬁbers, the patient defects by this method. The key elements are elevation of often tolerates a wound infection without the need to remove extensive ﬂaps of skin and subcutaneous tissue to expose the 106 Operations for Large Ventral Hernia 945 external oblique aponeurosis above and below the hernia sac. A longitudinal incision in the external oblique aponeuro- sis, just lateral to the lateral edge of the rectus muscle, allows the muscles to slide medially. This slide is enhanced by sepa- ration of the external oblique from the underlying internal oblique muscle as far laterally as can be achieved. This allows the rectus and internal oblique muscles to slide medi- ally and be closed without tension in the midline. Some sur- geons will add a sublay prosthetic patch to provide further reinforcement. Use of Drains Because most all repairs result in elevation of large subcuta- neous ﬂaps, many surgeons place closed-suction drains in the space between the subcutaneous tissue and the fascia to decrease seroma formation. A recent meta-analysis of the limited number of randomized trials (Gurusamy) failed to demonstrate any difference in outcome associated with drain placement. Operative Technique Elective Ventral Hernia Repair Dissecting the Hernial Sac Make an elliptical incision in the skin along the axis of the hernial ring and carry the incision down to the sac (Figs. Dissect the skin away from the sac on each side until the area of the hernial ring itself has been exposed in its entire circumference (Fig. Continue to dissect normal muscle fascia using a scalpel or Metzenbaum scissors until at least a 2 cm are freed of all adhesions around the entire circumference of width of fascia has been exposed around the entire circum- the hernia. For small defects, Mesh Repair of Ventral Hernia the hernia sac is usually removed (as described here). For large ventral hernias, it may be possible to keep the dissec- Sandwich Repair tion superﬁcial to the hernia sac, preserving it as a protective The “sandwich repair” was ﬁrst described by Usher. Two identical sheets of mesh are Resecting the Hernial Sac cut from a large sheet. Each piece of mesh should be 2 cm Make an incision along the apex of the hernial sac and divide larger than the hernial defect. One sheet is placed inside the all of the adhesions between the intestine and the sac abdominal cavity, and the other makes contact with the fas- (Figs. The two sheets are held by abdominal cavity after inspecting them for viability sutures that go through the top sheet, then through the full (Fig. Expose the circumference of the hernial defect thickness of the abdominal wall, and ﬁnally through the deep so the neck of the sac and a 2- to 3-cm width of peritoneum sheet of mesh. The deep layer of mesh should be sepa- which exposes healthy fascia around the entire circumfer- rated from the bowel by the omentum. In the absence of a ence of the hernial defect, make certain there are no addi- satisfactory layer of omentum, it may be preferable to omit tional hernial defects above or below the major hernia. If the intraperitoneal layer of mesh and to preserve enough her- there are additional hernias, combine them into one large nial sac so the sac, after being trimmed and sutured closed, defect by incising the bridge of tissue between them. Then insert one sheet of mesh inside the abdominal cavity and the other over the rectus fascia. Place the mattress sutures through the mesh at a point about 2–3 cm away from the hernial ring to be certain the sutures engage normal abdomi- nal muscle and aponeurosis. A horizontal mattress suture penetrates ﬁrst the superﬁcial layer of mesh, next the entire abdominal wall, and then the deep layer of mesh. When returning the suture, the width of the bite of mesh must be less than the width of the bite in the abdominal wall; other- wise, the mesh tends to bunch together when the stitch is tied rather than lying ﬂat. Therefore, when returning the stitch through the deep layer of mesh, select a spot that encom- passes only 7 mm of mesh while including a 1 cm width of Fig. Insert additional mattress the superﬁcial layer of the mesh and attach it to a Jackson- sutures of the same material at intervals of about 1. Approximate the skin with inter- until half of the sutures have been inserted and tied. After tying all the sutures, Onlay Patch Mesh Repair check for any possible defects in the repair (Figs. When a hernial defect borders on the pubis, include when there is no layer of omentum available to be interposed the periosteum of the pubis in the sutures attaching the mesh between the intestines and the mesh. This serves as a viable layer that hopefully will avoid the development of adhesions between the bowel and the mesh. The drawback to this tech- nique is that its sutures, compared with those of the sandwich technique, are weaker because the bites of tissue are not equivalent to those of large mattress sutures, which penetrate Fig. The ﬁrst stitch of 0 cephalad edge of the hernial defect is reached, insert a sec- Prolene starts at the caudal margin of the defect and catches ond stitch and tie it. Anchor the ﬁrst stitch by tying it to the 106 Operations for Large Ventral Hernia 951 a Fig. The second stitch runs in a continuous fashion along the opposite margin of the hernia and is termi- nated at the caudal edge of the hernial defect. Using a similar technique, stitch the edge of the mesh to the anterior layer of muscle fascia in a continuous fashion using atraumatic 2-0 Prolene (Fig. Insert a closed-suction catheter through a puncture wound and close the skin in routine fashion. Develop ﬂaps at the level Gently undermine the resulting ﬂap of external oblique between subcutaneous fat and musculoaponeurotic layers as muscle so that the muscle can retract laterally as the mid- far laterally as possible. Pull the midline together and assess nal oblique muscle just lateral to the lateral edge of the rectus tension, keeping in mind that muscle relaxation under abdominis muscle (Fig. Enter the plane slide, so that the resulting ﬂap of internal oblique muscle, deep to the external oblique and superﬁcial to the internal transversus abdominis muscle, and rectus will slide medi- oblique muscle. Note that the neurovascular structures pass ally and can be approximated in the midline without deep to the internal oblique muscle and should be preserved if tension. The new clamp to elevate the muscle and facilitate division of the arrangement of abdominal wall muscles is shown in external oblique for an ample distance above and below the Fig. If desired, a sublay patch (usually a biopros- cephalad and caudad extent of the hernia sac. Then require continuing the division up over the costal margin in recheck hemostasis and close the subcutaneous tissues and some cases. With proper precautions, wound infection should be rare following elective repair of a ventral hernia. If an infection of the subcutaneous wound does occur, it is not generally necessary to remove the mesh. Because of its monoﬁlament nature, polypropylene mesh with monoﬁla- ment Prolene sutures resists infection if the skin incision is promptly opened widely for drainage.
It is as effective as either ablative or additive therapies in treating hormone-sensitive cancers buy calcitriol 0.25 mcg with mastercard medications jfk was on. Tamoxifen is the most widely used hormonal treatment in breast cancer at the present day cheap calcitriol 0.25mcg without prescription medicine descriptions. The effect is greatest in patients aged over 50 years with positive nodes order calcitriol 0.25mcg on line symptoms kennel cough, in whom there is 20% reduction in annual mortality. As is the case for adjuvant chemotherapy, the effect of tamoxifen is found within the first 5-years and continues for at least 10 years. The role of adjuvant tamoxifen is now well established in women over 50 years of age. Tamoxifen is not without side-effects, particularly in premenopausal patients with nausea, weight gain, vaginal dryness or discharge. A 24% reduction in mortality in node-positive patients aged less than 50 years following oophorectomy have been noticed. Although there is a temptation to combine adjuvant chemotherapy with tamoxifen, there is no evidencr that their effects are additive. Under no circumstances therapy should exceed doses more than 20 mg and in excess of 5 years. Tamoxifen should better be given to women whose tumours are positive for hormone receptors. The notable amongst these is Zoladex — a luteinizing hormone releasing hormone antagonist. Its effect is same as chemical oophorectomy and has the same beneficial effects as surgical oophorectomy or irradiation oophorectomy in premenopausal women. In case of node-negative patients, tamoxifen reduces the clinical incidence of contralateral primary breast cancer. After conservative surgery radiotherapy to the remaining breast tissue was used as a routine procedure, but there is doubt whether all patients should receive such therapy or not. So at present, only patients with higher risk of local relapse and those with extensive carcinoma or carcinoma at the margins of excision should be offered postoperative radiotherapy. It has been shown that those women treated for breast cancer during the 2nd half of pregnancy did significantly less well than those treated in the 1st half of pregnancy or in the 1st six months postpartum. The following should be the mode of treatment for breast carcinoma in pregnancy and lactation — (a) In 1st half of pregnancy carcinoma should be treated with radical mastectomy without radiation or interruption of pregnancy, (b) When breast carcinoma is identified in the 2nd half of pregnancy, small lesions are not treated until after delivery. It must be remembered that patients below 35 years of age should be encouraged to be pregnant after a minimum one year interval following treatment for breast cancer. It is a revealed fact that those who had subsequent pregnancies following treatment for breast cancer had significantly better 10 year survival rate than those who did not become pregnant following mastectomy. This may be due to the interruption in the oestrogen stimulation process, as in pregnancy oestrogen level becomes lower than in non-pregnant state. After treatment of primary breast cancer approximately 1% of patients develop detectable breast cancer in the opposite breast each year. Yearly mammogram, frequent physical examinations are essential to detect such bilateral disease. For cosmetic reason one can always consider total mastectomy of the opposite breast with or without insertion of a silastic prosthesis. Those of greater frequency are misery of extensive ulcerating local disease, metastases in bone and dyspnoea from lesions in lungs. Admittedly, there is a wide choice of methods, but in this section, only available methods of treatment will be described. Once breast cancer has spread outside the confines of the breast and regional lymph nodes, it cannot be cured. In other words locally advanced breast cancer means a very large primary lesion with or without extensive nodal disease but having no detectable systemic metastasis. Locally advanced breast cancer is associated with poor prognosis and high local recurrence rate. Surgery alone is considered inadequate and multimodality treatment comprising chemotherapy, surgery and radiotherapy is advocated as the treatment of choice. Management of these cancers is somewhat disappointing because of poor local tumour control and high incidence of subsequent metastatic disease. There is probably little to choose between mastectomy and primary irradiation in the management of such cases. There are two principal objectives for the management of locally advanced breast cancer — (a) To achieve local control and (b) To prevent or delay the distant metastasis. Recently there has been enthusiasm for using adjuvant chemotherapy in these patients. After 6-drug cycles, an extended simple mastectomy (inclusive of level I nodes) is performed to remove residual malignant disease in the chest wall. After this multimodal therapy 5 and 10 year survival rates are reported as 45% and 28%. Mastectomy appears to be the appropriate initial treatment and use of breast-preserving procedure is not recommended. Even if metastases are present, the persistence of a tumour mass cause additional misery from ulceration or fungation. In these circumstances, operation is aimed at removal of the breast, containing its tumour. For the relief of functional disturbance resulting from deposits of the tumour in the abdominal cavity or spinal canal, surgery may be indicated. Sometimes acute intestinal obstruction may require bypass operation or impending paraplegia may require a laminectomy, decompression and spinal fusion oper ation. The major types of modalities which are in current use for palliation in advanced carcinomas of the breast are (i) Endocrine therapy, (ii) Chemotherapy and (iii) Radiotherapy. Those tumours which have hormone receptors, response rate to endocrine treatment is more than 50%. These combinations are standard care as the first attack on advanced breast cancer. Cyclophos phamide, which is a prototype alkylating agent and doxorubicin, which is an anthracycline antibiotic, considered to be the most active single agent in present days. For some patients who have troublesome local relapse of disease after combined chemotherapy, the surgeon may be able to salvage the local problem by performing mastectomy. Due to skin involvement it is necessary to take an extensive area of skin in excision, so that primary closure, even after undermining the edges, may not be possible. Under these circumstances skin cover can be achieved with either split skin graft or with a rotational myocutaneous flap. Management of relapse after adjuvant chemotherapy is as follows :— If the relapse is regional, the first treatment would usually be tumour excision followed by radiotherapy. For those who develop distant recurrences, the disease-free interval is an important indicator of the aggressiveness of the disease.