Salvage gamma knife surgery for recurrent glossopharyngeal neuralgia following microvascular decompression: a retrospective case series.

BACKGROUND: Although microvascular decompression (MVD) is recognized as the preferred therapy for drug-resistant idiopathic glossopharyngeal neuralgia (GPN), the management of recurrent GPN following MVD is seldom mentioned in the current literature. This study aims to demonstrate the efficacy and safety of salvage Gamma Knife surgery (GKS) in the treatment of recurrent GPN after MVD. METHODS: From October 2012 to January 2018, seven patients (three males and four females) underwent salvage GKS for recurrent GPN following MVD, including two patients who received repeat GKS due to pain recurrence after their initial GKS salvage. The median age was 69 years (range 49-81 years) at first GKS and 72 years (67 years; 77 years) at second GKS. The delivered dose was 80 or 90 Gy at first GKS and 90 Gy at second GKS. Pain outcome was assessed according to the Barrow Neurological Institute (BNI) score. RESULTS: The median duration of follow-up after first GKS was 68 months (range 29-89 months) and 45 months (56 months; 33 months) after second GKS. The median time to pain response was 24 days (range, 6-80 days). One patient experienced palatoglossal hyperesthesia after first GKS, and no complications were noted after second GKS. At the last follow-up, 4 patients were BNI I, 1 was BNI II, and 2 was BNI IIIa. CONCLUSIONS: Salvage GKS is safe and effective for treating recurrent GPN after MVD, even for patients who experienced pain recurrence following their initial GKS salvage.

Impact of Long-Course Neoadjuvant Radiation on Postoperative Low Anterior Resection Syndrome and Quality of Life in Rectal Cancer: Post Hoc Analysis of a Randomized Controlled Trial.

BACKGROUND: Neoadjuvant radiation is recommended for locally advanced rectal cancer, with proven benefit in local control but not in disease-free survival. However, the impact of long-course radiation on postoperative bowel function and quality of life (QOL) remains controversial. This study aimed to investigate the impact of long-course neoadjuvant radiation on bowel function and QOL, and to identify risk factors for severe bowel dysfunction. METHODS: Patients who underwent long-course neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by radical low anterior resection for locally advanced rectal cancer were recruited from the FOWARC randomized controlled trial. Low anterior resection syndrome (LARS) score and European Organisation for Research and Treatment of Cancer (EORTC) C30/CR29 questionnaires were used to assess bowel function and QOL, respectively. RESULTS: Overall, 220 patients responded after a median follow-up of 40.2 months, of whom 119 (54.1%) reported major LARS, 74 (33.6%) reported minor LARS, and 27 (12.3%) reported no LARS. Compared with the nCT group, the nCRT group reported more major LARS (64.4% vs. 38.6%, p < 0.001) and worse QOL. Long-course neoadjuvant radiation (OR 2.20, 95% CI 1.24-3.91; p = 0.007), height of anastomosis (OR 0.74, 95% CI 0.63-0.88; p < 0.001), and diverting ileostomy (OR 2.59, 95% CI 1.27-5.30; p = 0.009) were independent risk factors for major LARS. CONCLUSIONS: Long-course neoadjuvant radiation, along with low anastomosis, are likely independent risk factors for postoperative bowel function and QOL. Our findings might have implications for alleviating LARS and improving QOL by informing selection of neoadjuvant treatment.

Does enhanced recovery improve the survival rates of patients 3 years after undergoing surgery to remove a tumor in the colon?

PURPOSE: The advantages of enhanced recovery programs (ERP) after colorectal surgery for morbidity and length of stay are well known. On a longer term, evidence is much more limited. The aim of this study is to determine the impact of ERP on survival after 3 years of follow-up, following colorectal cancer surgery. METHODS: All the patients undergoing resection for colorectal cancer between the years 2010 and 2014 were included. Patients were classified according to their compliance with the ERP (< 70 or ≥ 70%). RESULTS: Among the 206 patients included during the period, 129 were male (62.6%). The 3-year overall survival rate was 70.4% (145 patients) and relapse-free survival was 59.2% (122 patients). The survival after 3 years was influenced by the initial metastatic status (p < 0.0001), operative morbidity (p < 0.001), and the presence of peritumoral emboli (p = 0.006). However, the compliance with the ERP ≥ 70% did not influence overall survival (p = 0.63), nor relapse-free survival (p = 0.93). The same observations were found among the "at-risk" population (synchronous metastasis and postoperative complication). CONCLUSION: The ERP does not seem to influence the 3-year relapse-free survival after colorectal resection for cancer.

Parathyroid carcinoma arising from auto-transplanted parathyroid tissue after Total Parathyroidectomy in chronic kidney disease patient: a case report.

BACKGROUND: Secondary hyperparathyroidism is a common complication in patients with chronic kidney disease that requires vigilant treatment due to its high mortality rate. Pharmacologic therapy is recommended as an initial treatment; if there is no response, a total parathyroidectomy is performed. In some cases, surgery is accompanied by auto-transplantation of parathyroid tissue. CASE PRESENTATION: The patient was diagnosed with chronic kidney disease and received a kidney transplant. However, due to rejection of the transplanted kidney, medical nephrectomy was carried out and routine hemodialysis was initiated and observed. At this time, secondary hyperparathyroidism with elevated parathyroid hormone and hyperphosphatemia developed and pharmacologic treatment was applied. However, there was no response to pharmacologic treatment; therefore, total parathyroidectomy with auto-transplantation was performed. Eight years after surgery, a growing mass was observed in the transplantation site, accompanied by an elevation of parathyroid hormone. A complete resection of the mass was performed, and the patient was diagnosed with parathyroid carcinoma. Additional adjuvant radiation therapy was ordered, and the patient is being monitored. CONCLUSIONS: This is a rare but remarkable case of parathyroid carcinoma arising from auto-transplanted parathyroid tissue after total parathyroidectomy in a patient with secondary hyperparathyroidism. We suggest caution should be taken when choosing to auto- transplant parathyroid tissue and that careful postoperative observation should be performed.

Salvage radiotherapy for macroscopic local recurrences after radical prostatectomy : A national survey on patterns of practice.

INTRODUCTION: Although salvage radiotherapy (SRT) for PSA recurrence after radical prostatectomy provides better oncological outcomes when delivered early, in the absence of detectable disease many patients are treated for macroscopic locally recurrent tumors. Due to limited data from prospective studies, we hypothesized an important variability in the SRT management of these patients. Our aim was to investigate current practice patterns of SRT for local macroscopic recurrence after radical prostatectomy. MATERIAL AND METHODS: A total of 14 Swiss radiation oncology centers were asked to complete a survey on treatment specifications for macroscopic locally recurrent disease including information on pretherapeutic diagnostic procedures, dose prescription, radiation delivery techniques and androgen deprivation therapy (ADT). Treatment recommendations on ADT were analyzed using the objective consensus methodology. RESULTS: The majority of centers recommended pretreatment magnetic resonance imaging (MRI) of the pelvis and choline positron emission tomography (PET). The median prescribed dose to the prostate bed was 66 Gy (range 65-72 Gy) with a boost to the macroscopic lesion used by 79% of the centers with a median total dose of 72 Gy (range 70-80 Gy). Intensity-modulated rotational techniques were used by all centers and daily cone beam computed tomography (CT) was recommended by 43%. The use of concomitant ADT for any macroscopic recurrence was recommended by 43% of the centers while the remaining centers recommended it only for high-risk disease, which was not consistently defined. CONCLUSION: We observed a high variability of treatment paradigms when SRT is indicated for macroscopic local recurrences after prostatectomy. These data reflect the need for more standardized approaches and ultimately further research in this field.

Hypothyroidism and hyponatremia: data from a series of patients with iatrogenic acute hypothyroidism undergoing radioactive iodine therapy after total thyroidectomy for thyroid cancer.

PURPOSE: The aim of the present study was to evaluate the role of hypothyroidism as a cause of hyponatremia in a clinical model of iatrogenic acute hypothyroidism due to thyroid hormone withdrawal prior to ablative radioactive iodine (RAI) therapy after total thyroidectomy. METHODS: The study group consisted of 101 differentiated thyroid cancer (DTC) patients (77 women and 24 men). Plasma concentration of thyroid-stimulating hormone ([TSH]) and sodium ([Na+]) was evaluated before total thyroidectomy (pre[TSH] and pre[Na+]) and on the day of RAI therapy (post[TSH] and post[Na+]). RESULTS: The frequency of hypothyroidism-associated hyponatremia was 4 % (4/101). Pre[Na+] was significantly higher than post[Na+] (140.7 ± 1.6 vs 138.7 ± 2.3 mEq/L, p = 0.012). Moreover, a linear correlation was identified between pre[Na+] and post[Na+]. CONCLUSIONS: Iatrogenic acute hypothyroidism-related hyponatremia is uncommon. However, because of the significant reduction of [Na+] in the transition from euthyroidism to iatrogenic hypothyroidism, the value of pre[Na+] should be viewed as a parameter to be considered. Since it acts as an independent risk factor for the development of hyponatremia, patients with a pre[Na+] close to the lower limit of normal range may deserve a closer monitoring of [Na+].

Is Low-Level Laser Therapy Effective for Treatment of Neurosensory Deficits Arising From Sagittal Split Ramus Osteotomy?

PURPOSE: This study investigated the effectiveness of low-level laser therapy (LLLT) for treating neurosensory impairment after bilateral sagittal split osteotomy (BSSO). MATERIALS AND METHODS: This randomized, double-blinded, split-mouth trial included patients requiring BSSO. After surgery, 1 side of each patient was randomly assigned to laser therapy and the other side served as the control. At 24, 48, and 72 hours after surgery, LLLT was accomplished by intraoral application of a 660-nm laser around the surgical site (200 mW, 10 seconds, 2 J, 1.5 J/cm2) followed by extraoral irradiation by an 810-nm laser (200 mW, 10 seconds, 2 J, 7 J/cm2) along the distribution of the inferior alveolar nerve. Subsequently, extraoral irradiation was repeated 2 times per week for 3 weeks along the path of the inferior alveolar nerve, lower lip, and chin. On the control side, the treatment was similar to the laser side but with laser simulation. The main outcome was assessing nerve damage by a "2-point discrimination test" before and up to 60 days after surgery. RESULTS: The sample consisted of 16 patients. No significant difference was found between the laser and control sides before and after surgery and on postoperative days 15 and 30 (P > .05). The 2-point discrimination distance was significantly shorter on the laser side than on the control side on postoperative days 45 and 60 (P < .05). CONCLUSION: LLLT was effective in the treatment of neurosensory disturbances arising from BSSO. Therefore, LLLT can be recommended to accelerate the recovery of sensory aberrations in patients undergoing BSSO.

Far-infrared ray for treating chronic lower extremity lymphedema with dermatolymphangioadenitis: a postoperative complication of gynecological tumor resection.

PURPOSE: Lower extremity lymphedema is regarded as a relatively common postoperative complication and is often accompanied with dermatolymphangioadenitis (DLA). This study combines clinical assessment and laboratory investigation to explore therapeutic effects of far-infrared radiation (FIR) therapy for chronic lower extremity lymphedema accompanied with DLA, occurring after gynecological tumor resection. METHODS: Patients who met inclusion and exclusion criteria would be enrolled. They received regular sessions using the FIR therapy machine over the 4-week treatment course. Clinical and laboratory outcome measures were carried out before and after treatment. Clinical outcome measures included DLA seizure frequency (episodes/year), patients' subjective feedback for lymphedema-related symptoms and quality of life (QOL). Laboratory outcome measures included bacterial cultures and concentrations of inflammatory cytokines: IL-1ß, IL-2, IL-4, IL-10, IL-12, IL-18, TNF-α, TNF-ß, caspase-1 and INF-γ, detected in serum and local lymphedema tissue fluid samples using protein microarray and ELISA. RESULTS: Between 2012 and 2016, a total of 120 female patients were screened for study enrollment. Sixty-four recruited patients underwent clinical evaluation both before FIR radiation therapy and 1 year after a single course of FIR radiation therapy. Eleven patients (17.2%), randomly chosen from the study group, underwent additional laboratory analysis of blood and local lymphedema tissue fluid samples. The frequency of DLA decreased following treatment (p < 0.001). Fifty patients (78%) did not experience a single episode of DLA recurrence in the year subsequent to treatment. The efficiency rate calculated using DLA frequencies was greater than 50% for 63 (98%) patients following treatment. Patients reported a subjective decrease in lymphedema-related symptoms (p < 0.05). Patients' QOL scores were higher after treatment (p < 0.001). Laboratory analysis showed an elevation in serum concentration of IL-1ß after FIR therapy (p < 0.05) and reduced local tissue fluid concentrations of inflammatory cytokines IL-2, IL-10 and IL-18 (p < 0.05). Bacterial culture results before and after treatment were both negative. CONCLUSION: FIR radiation therapy provides an effective treatment modality for patients with chronic lymphedema accompanied with DLA that develops secondarily to treatment of gynecological malignancies, whose therapeutic effects may be due to reduced immune dysfunction within local lymphedema tissues.

Effect of Low-Level Laser and Light-Emitting Diode on Inferior Alveolar Nerve Recovery After Sagittal Split Osteotomy of the Mandible: A Randomized Clinical Trial Study.

PURPOSE: The major concern of sagittal split osteotomy (SSO) is the neurosensory disturbance. The authors investigated the effect of low-level laser therapy and light-emitting diode on the inferior alveolar nerve recovery after SSO. METHODS: In this double-blinded randomized clinical trial, 20 subjects with inferior alveolar nerve injury after SSO of the mandible were studied. Neurosensory recovery was assessed by 6 tests: visual analog scale (VAS), brush stroke, 2-point discrimination, contact detect detection, pinprick nociception, and thermal discrimination, and each one was performed before and after the surgery on days 1, 3, 7, 14, 60, and 180. RESULTS: After 1 week, the VAS score in the laser group significantly improved in comparison with the control group. Visual analog scale score improvement was 25% (P = 0.015) at 2 weeks, 21% (P = 0.001) at 2 months, and 24% (P = 0.001) at 6 months. After 2 weeks, the brush stroke score improvement was significant in the laser group. The improvement values were 21.5% (P = 0.002) at 2 months and 15.1% (P = 0.004) at 6 months. CONCLUSION: Low-level laser therapy and light-emitting diode may improve VAS scores, 2-point discrimination, and brush stroke test results without any effect on the pinprick or contact detection test results.

A 1-Year Follow-Up of Post-operative Scars After the Use of a 1210-nm Laser-Assisted Skin Healing (LASH) Technology: A Randomized Controlled Trial.

BACKGROUND: Laser therapies are used prophylactically for excessive scar formation. The Laser-Assisted Skin Healing treatment induces a controlled heat stress that promotes tissue regeneration. This comparative trial is the first to evaluate the performance of a new automated 1210-nm laser system, compatible with all Fitzpatrick scale phototypes. METHODS: Forty women undergoing bilateral breast reduction were enrolled in this double-blinded randomized controlled trial. The horizontal sutured incision of one breast was treated with the portable 1210-nm laser while in the operating theatre. The other breast was used as the study control. Objective measurements, subjective clinical assessments and safety evaluation were carried out over 1 year by both clinicians and patients. RESULTS: Six weeks following surgery, better overall appearance and modified OSAS scores were reported for the laser-treated scars when compared to the control group (p = 0.024 and p = 0.079). This supports an early effect of the laser treatment during the inflammatory stage of the healing process. After a post-treatment period of 6 months, there continued to be a strong tendency in favour of the laser treatment based on the subjective scores and corroborated by the objective improvement of the treated scar volume (p = 0.038). At 1 year, the laser-treated scars continued to improve compared to the control ones in terms of volume (p = 0.004), surface (p = 0.017) and roughness (p = 0.002), and these comparatively better results were strengthened with the blind expression of patients' preference for their laser-treated scar (p = 0.025). CONCLUSIONS: This new 1210-nm laser treatment, used as a single session performed immediately after surgery, provides significant objective and subjective improvements in scar appearance. These data can be useful when preparing patients to undergo their surgical procedure. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Low-level laser therapy for treatment of neurosensory disorders after orthognathic surgery: A systematic review of randomized clinical trials.

BACKGROUND: Low-level laser has been widely used in Dentistry and many studies have focused on its application in oral surgeries. This study was conducted with the aim of searching for scientific evidence concerning the effectiveness of laser to reduce pain or paresthesia related to orthognathic surgery. MATERIAL AND METHODS: An electronic search was performed in PubMed, Scopus, Science Direct, LILACS, SciELO, CENTRAL, Google Scholar, OpenGrey, and ClinicalTrials.gov, up to November 2016, with no restrictions on language or year of publication. Additionally, a hand search of the reference list of the selected studies was carried out. The PICOS strategy was used to define the eligibility criteria and only randomized clinical trials were selected. RESULTS: Out of 1,257 identified citations, three papers fulfilled the criteria and were included in the systematic review. The risk of bias was assessed according to the Cochrane Guidelines for Clinical Trials and results were exposed based on a descriptive analysis. One study showed that laser therapy was effective to reduce postoperative pain 24 hours (P=0.007) and 72 hours (P=0.007) after surgery. Other study revealed the positive effect of laser to improve neurosensory recovery 60 days after surgery, evaluated also by the two-point discrimination (P=0.005) and sensory (P=0.008) tests. The third study reported an improvement for general sensibility of 68.75% for laser group, compared with 21.43% for placebo (P=0.0095), six months after surgery. CONCLUSIONS: Individual studies suggested a positive effect of low-level laser therapy on reduction of postoperative pain and acceleration of improvement of paresthesia related to orthognathic surgery. However, due to the insufficient number and heterogeneity of studies, a meta-analysis evaluating the outcomes of interest was not performed, and a pragmatic recommendation about the use of laser therapy is not possible. This systematic review was conducted according to the statements of PRISMA and was registered at PROSPERO under the number CRD42016043258.

Preoperative or postoperative radiotherapy versus surgery alone for retroperitoneal sarcoma: a case-control, propensity score-matched analysis of a nationwide clinical oncology database.

BACKGROUND: Recruitment into clinical trials for retroperitoneal sarcoma has been challenging, resulting in termination of the only randomised multicentre trial in the USA investigating perioperative radiotherapy. Nonetheless, use of radiotherapy for retroperitoneal sarcoma has increased over the past decade, substantiated primarily by its established role in extremity sarcoma. In this study, we used a nationwide clinical oncology database to separately compare overall survival for patients with retroperitoneal sarcoma who had surgery and preoperative radiotherapy or surgery and postoperative radiotherapy versus surgery alone. METHODS: We did two case-control, propensity score-matched analyses of the National Cancer Data Base, which included adult patients with retroperitoneal sarcoma who were diagnosed from 2003 to 2011. Patients were included if they had localised, primary retroperitoneal sarcoma. Patients were classified into three groups based on use of radiotherapy: preoperative radiotherapy, postoperative radiotherapy, and no radiotherapy (surgery alone). Patients were excluded if they received both preoperative radiotherapy and postoperative radiotherapy, or if they received intraoperative radiotherapy. Parallel propensity score-matched datasets were created for patients who received preoperative radiotherapy versus those who received no radiotherapy and for patients who received postoperative therapy versus those who received no radiotherapy. Propensity scores were calculated with logistic regression, with multiple imputation and backwards elimination, with a significance level to stay of 0·05. Matching was done with a nearest-neighbour algorithm and matched 1:2 for the preoperative radiotherapy dataset and 1:1 for the postoperative radiotherapy dataset. The primary objective of interest was overall survival for patients who received preoperative radiotherapy or postoperative radiotherapy compared with those who received no radiotherapy within the propensity score-matched datasets. FINDINGS: 9068 patients were included in this analysis: 563 in the preoperative radiotherapy group, 2215 in the postoperative radiotherapy group, and 6290 in the no radiotherapy group. Matching resulted in two comparison groups (preoperative radiotherapy vs no radiotherapy, and postoperative radiotherapy vs no radiotherapy) with negligible differences in all demographic, clinicopathological, and treatment-level variables. In the matched case-control analysis for preoperative radiotherapy median follow-up time was 42 months (IQR 27-70) for the preoperative radiotherapy group versus 43 months (25-64) for the no radiotherapy group; median overall survival was 110 months (95% CI 75-not estimable) versus 66 months (61-76), respectively. In the matched case-control analysis for postoperative radiotherapy median follow-up time was 54 months (IQR 32-79) for patients in the postoperative radiotherapy group and 47 months (26-72) for patients in the no radiotherapy group; median overall survival was 89 months (95% CI 79-100) versus 64 months (59-69), respectively. Both preoperative radiotherapy (HR 0·70, 95% CI 0·59-0·82; p<0·0001) and postoperative radiotherapy (HR 0·78, 0·71-0·85; p<0·0001) were significantly associated with improved overall survival compared with surgery alone. INTERPRETATION: To the best of our knowledge, this is the largest study to date of the effect of radiotherapy on overall survival in patients with retroperitoneal sarcoma. Radiotherapy was associated with improved overall survival compared with surgery alone when delivered as either preoperative radiotherapy or postoperative radiotherapy. Together with the results from the ongoing randomised EORTC trial (62092-22092; NCT01344018) investigating preoperative radiotherapy for retroperitoneal sarcoma pending, these data might provide additional support for the increasing use of radiotherapy for patients with retroperitoneal sarcoma undergoing surgical resection. FUNDING: Department of Surgery, Duke University School of Medicine.

Prophylactic radiotherapy for the prevention of procedure-tract metastases after surgical and large-bore pleural procedures in malignant pleural mesothelioma (SMART): a multicentre, open-label, phase 3, randomised controlled trial.

BACKGROUND: The use of prophylactic radiotherapy to prevent procedure-tract metastases (PTMs) in malignant pleural mesothelioma remains controversial, and clinical practice varies worldwide. We aimed to compare prophylactic radiotherapy with deferred radiotherapy (given only when a PTM developed) in a suitably powered trial. METHODS: We did a multicentre, open-label, phase 3, randomised controlled trial in 22 UK hospitals of patients with histocytologically proven mesothelioma who had undergone large-bore pleural interventions in the 35 days prior to recruitment. Eligible patients were randomised (1:1), using a computer-generated sequence, to receive immediate radiotherapy (21 Gy in three fractions within 42 days of the pleural intervention) or deferred radiotherapy (same dose given within 35 days of PTM diagnosis). Randomisation was minimised by histological subtype, surgical versus non-surgical procedure, and pleural procedure (indwelling pleural catheter vs other). The primary outcome was the incidence of PTM within 7 cm of the site of pleural intervention within 12 months from randomisation, assessed in the intention-to-treat population. This trial is registered with ISRCTN, number ISRCTN72767336. FINDINGS: Between Dec 23, 2011, and Aug 4, 2014, we randomised 203 patients to receive immediate radiotherapy (n=102) or deferred radiotherapy (n=101). The patients were well matched at baseline. No significant difference was seen in PTM incidence in the immediate and deferred radiotherapy groups (nine [9%] vs 16 [16%]; odds ratio 0·51 [95% CI 0·19-1·32]; p=0·14). The only serious adverse event related to a PTM or radiotherapy was development of a painful PTM within the radiotherapy field that required hospital admission for symptom control in one patient who received immediate radiotherapy. Common adverse events of immediate radiotherapy were skin toxicity (grade 1 in 50 [54%] and grade 2 in four [4%] of 92 patients vs grade 1 in three [60%] and grade 2 in two [40%] of five patients in the deferred radiotherapy group who received radiotherapy for a PTM) and tiredness or lethargy (36 [39%] in the immediate radiotherapy group vs two [40%] in the deferred radiotherapy group) within 3 months of receiving radiotherapy. INTERPRETATION: Routine use of prophylactic radiotherapy in all patients with mesothelioma after large-bore thoracic interventions is not justified. FUNDING: Research for Patient Benefit Programme from the UK National Institute for Health Research.

The impact of postoperative radiation therapy on patterns of failure and survival improvement in patients with intracranial hemangiopericytoma.

Because of the rarity of intracranial hemangiopericytomas (HPCs), the role of postoperative radiation therapy (PORT) in the management of HPC remains unclear. This study therefore analyzed the effects of PORT on patterns of failure and survival improvement in patients with HPC. Fifty-two patients surgically treated for intracranial HPC at our institution between 1992 and 2013 were retrospectively analyzed. Patterns of failure were subdivided into local recurrence, regional metastasis, and distant metastasis. Multivariate Cox proportional hazards models were used to assess factors prognostic of treatment failure and survival, and a time-dependent Cox proportional hazards models were used to investigate the correlations between patterns of failure and death. Of the 52 patients, 45 (87 %) underwent gross total resection, and 39 (75 %) received PORT. PORT significantly lengthened local control (LC) and overall survival (OS), by 14 and 13 months, respectively, independent of the extent of resection. Patients who did and did not receive PORT had 5 year LC rates of 97 and 44 %, respectively (HR .05, P = .002); and 10 year OS rates of 83 and 25 %, respectively (hazard ratio (HR) .20, P = .008). PORT, however, did not show preventive effects on regional and distant metastases. The main patterns of failure were local recurrence in patients who did not receive PORT and distant metastasis in those who received PORT. Regional metastasis was a main immediate cause of death (P < .001), and tended to occur more frequently and earlier in patients not receiving PORT.

Comparison of 532 nm Potassium Titanyl Phosphate Laser and 595 nm Pulsed Dye Laser in the Treatment of Erythematous Surgical Scars: A Randomized, Controlled, Open-Label Study.

BACKGROUND: The pulsed dye laser (PDL) has long been used for treatment of erythematous and hypertrophic scars. Its effectiveness has been attributed in large part to its vascular-specificity. The vascular-specific potassium titanyl phosphate (KTP) laser has also been reported to be clinically effective for scars, but has not been compared to the PDL. OBJECTIVE: To compare the safety and clinical efficacy of a 532-nm KTP laser versus a 595-nm PDL in improving the appearance of erythematous surgical scars. METHODS: Twenty patients with matched bilateral erythematous surgical scars or a single linear erythematous scar measuring longer than 5 cm were enrolled in the study. Single scars were divided into equal halves with each half randomized to receive 3 successive treatments at 6-week intervals with either a 532-nm KTP laser (Excel V; Brisbane, CA) or a 595-nm PDL (Cynergy; Cynosure Inc., Chelmsford, MA) at equivalent laser parameters. Bilateral matched scars were similarly randomized to receive three 532-nm KTP or 595-nm PDL treatments. Clinical efficacy was evaluated 12 weeks after the third (final) laser treatment by independent, blinded photographic scar assessments. Secondary evaluations included final investigator and subject treatment/satisfaction assessments, Vancouver scar scale (VSS) scores, subject scar symptoms, intraoperative pain scores, and incidence of side effects. RESULTS: Clinical improvement of erythematous surgical scars was observed with both 532-nm KTP and 595-nm PDL systems. No statistically significant differences between the 2 treatment arms were noted in the independent, blinded photographic scar assessments, investigator and subject treatment/satisfaction assessments, subject scar symptoms, and intraoperative pain scores. The KTP arm produced statistically significant improvement for the vascularity component of the VSS only. Side effects were limited to mild treatment discomfort and minimal transient post-treatment erythema and purpura. No vesiculation, infection, scarring or other adverse events were experienced. Subject satisfaction surveys mirrored the observed clinical effects. CONCLUSION: The-532 nm KTP laser is comparable in efficacy and safety to the 595-nm PDL laser in the treatment of erythematous surgical scars.

Recurrent Hemarthroses After TKA Treated With an Intraarticular Injection of Yttrium-90.

BACKGROUND: Recurrent hemarthroses after a TKA are uncommon and usually respond to nonoperative treatment or intervention using angiographic embolization or synovectomy. However, in rare circumstances, the problem can be resistant to treatment. CASE DESCRIPTION: We report the case of a patient who had recurrent hemarthroses after a TKA. During the first 18 months after surgery, the patient experienced 48 episodes consistent with bleeding into the knee. The bleeding episodes recurred despite use of traditional treatments, including arthroscopy, open synovectomy and embolization of a small, false aneurysm. The patient ultimately received an intraarticular injection of yttrium-90 silica/citrate, and the hemarthroses ceased soon after the injection. At last review, 25 months after the injection, the patient had experienced no additional bleeding episodes. LITERATURE REVIEW: On review of the literature, we found only one other report in which yttrium-90 was used successfully in a similar situation. CLINICAL RELEVANCE: Yttrium-90 may be considered a treatment option in patients with recurrent hemarthroses after TKA, especially when the condition has not responded to more traditional treatments. The long-term risk of treatment with yttrium-90 for recurrent hemarthroses after a TKA remains unclear.

Postoperative Critical Care of the Adult Cardiac Surgical Patient: Part II: Procedure-Specific Considerations, Management of Complications, and Quality Improvement.

OBJECTIVES: The armamentarium of cardiac surgery continues to expand, and the cardiac intensivist must be familiar with a broad spectrum of procedures and their specific management concerns. In the conclusion of this two-part review, we will review procedure-specific concerns after cardiac surgery and the management of common complications. We also discuss performance improvement and outcome assurance. DATA SOURCE AND SYNTHESIS: Narrative review of relative English language peer-reviewed medical literature. CONCLUSIONS: Knowledge of procedure-specific sequelae informs anticipation and prevention of many complications after cardiac surgery. Most complications after cardiac surgery fall into a limited number of categories. Familiarity with common complications combined with a structured approach to management facilitates response to even the most complicated postoperative situations. Standardized care and constant self-examination are essential for programmatic improvement and consistent high-quality care.

Successful radiation treatment of chylous ascites following pancreaticoduodenectomy.

Chylous ascites is a rare complication following pancreaticoduodenectomy. We report on a case of chylous ascites following pancreaticoduodenectomy in a 76-year-old patient diagnosed with pancreatic cancer. There are various known conservative management strategies, including dietary measures or total parenteral nutrition. Unfortunately, conservative treatment-with total parenteral nutrition and fasting over a period of 4 weeks-was not successful in the present case. The daily output volume of chylous ascites was up to 2500 ml/day. Based on clinical experiences with successfully treated lymphocutaneous fistulas, low-dose radiotherapy was initiated. External beam radiotherapy comprising a total dose of 8.0 Gy to the paraaortic lymph node region was administered in daily single fractions of 1.0 Gy (five fractions/week). Throughout the course of external beam radiotherapy, the secretion of abdominal ascites rapidly decreased, resulting in complete resolution after 2 weeks. There was no clinical evidence of chylous ascites on follow-up. As a result of this experience, we believe that external beam radiotherapy should be considered as an alternative therapy in refractory cases of chylous ascites.

Pulsed Dye Laser for Early Treatment of Scars After Dermatological Surgery.

BACKGROUND: Wound healing is a complex process; during the process angiogenesis takes place, that presents clinically as erythema, telangiectasia and edema. Pulsed dye laser (PDL) has a wavelength of 585-595 nm, which targets the chromophore hemoglobin. OBJECTIVE: Determine the level of improvement of post-dermatological surgery scars. METHODS: Thirty patients attending for excision lesion were recruited. They were randomized to 1 of 2 groups. Group 1 scar was randomly divided into 2 parts, one half received PDL 595 nm on 3 occasions; the first after suture removal, 15 and 45 days. Group 2 in one half laser application was simulated while the other was left untreated. The Vancouver scar scale (VSS) was used by an external evaluator to assess the scars. Two skin biopsies were also obtained one before and one after laser treatment. RESULTS: The VSS at 45 days decreased in a significant way in the treatment group from 4 to 1 (P = .005). In the control group decreased from 2 to 1.3 (P = .056). No significant difference was found between the presence of inflammatory infiltrate of patients in the placebo group. CONCLUSION: This study confirmed the usefulness of pulsed dye laser for improving the appearance of scars.