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

Pseudoangiomatous stromal hyperplasia (PASH) is a benign entity of the breast and typically found incidentally. It warrants thorough investigation in order to exclude more sinister pathology masquerading as this form of benign breast disease and can often be managed expectantly without the need for surgical intervention. We provide a brief review of the literature on PASH, discussing its clinicopathological features and management.

INTRODUCTION Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated.METHODS A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances.RESULTS 118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine.CONCLUSIONS The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants -systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

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BackgroundImplant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK. The introduction of techniques to augment the subpectoral pocket has revolutionised the procedure, but there is a lack of high-quality outcome data to describe the safety or effectiveness of these techniques. Randomised controlled trials (RCTs) are the best way of comparing treatments, but surgical RCTs are challenging. The iBRA (implant breast reconstruction evaluation) study aims to determine the feasibility, design and conduct of a pragmatic RCT to examine the effectiveness of approaches to IBBR.Methods/designThe iBRA study is a trainee-led research collaborative project with four phases:Phase 1 – a national practice questionnaire (NPQ) to survey current practicePhase 2 – a multi-centre prospective cohort study of patients undergoing IBBR to evaluate the clinical and patient-reported outcomesPhase 3– an IBBR-RCT acceptability survey and qualitative work to explore patients’ and surgeons’ views of proposed trial designs and candidate outcomes.Phase 4 – phases 1 to 3 will inform the design and conduct of the future RCT All centres offering IBBR will be encouraged to participate by the breast and plastic surgical professional associations (Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons).Data collected will inform the feasibility of undertaking an RCT by defining current practice and exploring issues surrounding recruitment, selection of comparator arms, choice of primary outcome, sample size, selection criteria, trial conduct, methods of data collection and feasibility of using the trainee collaborative model to recruit patients and collect data.DiscussionThe preliminary work undertaken within the iBRA study will determine the feasibility, design and conduct of a definitive RCT in IBBR. It will work with the trainee collaborative to build capacity by creating an infrastructure of research-active breast and plastic surgeons which will facilitate future high-quality research that will ultimately improve outcomes for all women seeking reconstructive surgery.Trial registration ISRCTN37664281