RESUMO
BACKGROUND: Image-guided microwave ablation (MWA) is a technically demanding procedure, involving advanced visual-spatial perception skills. This study sought to create and evaluate a low-cost model and training curriculum for open ultrasound-guided liver tumor MWA. METHODS: Simulated tumors were created, implanted into bovine livers, and visualized by ultrasound. A high-fidelity abdominal model was constructed, with a total cost of $30. Experienced physicians in MWA performed simulated ablations and evaluated the model. Expert performance metrics were established and served as targets for our training curriculum. These included time, number of passes, number of repositionings, and percentage of tumor ablated. Next, 8 novice trainees completed our deliberate practice curriculum. Participants' performances were recorded throughout. RESULTS: Physicians completed a structured feedback questionnaire rating the model's realism and training utility at 8/10 and 10/10, respectively. Tumors appeared hyperechoic and were clearly visualized on ultrasound. Trainees performed a total of 32 ablations. Our trainees' performance improved significantly in all outcomes of interest in the postcurriculum ablations compared to precurriculum ablations. CONCLUSION: We have created a cost-effective, high-fidelity model of MWA, with a deliberate practice curriculum. Trainees can practice to proficiency with clear target metrics prior to participating in clinical cas.
Assuntos
Técnicas de Ablação/educação , Currículo , Hepatectomia/educação , Neoplasias Hepáticas/cirurgia , Modelos Educacionais , Cirurgia Assistida por Computador/educação , Ultrassonografia de Intervenção , Animais , Bovinos , Hepatectomia/métodosRESUMO
BACKGROUND: We compared characteristics and outcomes of palpable versus nonpalpable, hormone-sensitive, early-stage breast cancers. METHODS: Patients from the North American Fareston vs. Tamoxifen Adjuvant (NAFTA) trial were divided into palpable (nâ¯=â¯513) and nonpalpable (nâ¯=â¯1063) tumor groups. Differences in pathological features, loco-regional therapy, disease-free survival (DFS) and overall survival (OS) were analyzed. RESULTS: Patients with palpable tumors were older, had larger tumors, and higher rates of lymph-node involvement. The tumors were more likely to be poorly differentiated, of high nuclear grade, and display lymphovascular invasion. After mean followup of 59 months, DFS and OS were significantly lower for palpable than nonpalpable tumors (DFS 93.5% vs. 98.4%, pâ¯<â¯0.001, OS 88.5% vs. 95.6%, pâ¯<â¯0.001). Controlling for age, size and nodal status, palpability was an independent factor for DFS (ORâ¯=â¯2.56; 95%CI, 1.37-4.79, pâ¯=â¯0.003) and OS (ORâ¯=â¯2.12; 95%CI, 1.38-3.28, pâ¯<â¯0.001). CONCLUSIONS: In a group of hormone-sensitive, mostly postmenopausal early-stage breast cancer patients, palpable tumors were more likely to have more aggressive features and metastatic potential, which translated in to a higher incidence of breast cancer-related events and worse overall survival.
Assuntos
Neoplasias da Mama/diagnóstico , Detecção Precoce de Câncer/métodos , Palpação/métodos , Receptores de Estrogênio/metabolismo , Tamoxifeno/administração & dosagem , Toremifeno/administração & dosagem , Idoso , Antineoplásicos Hormonais/administração & dosagem , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/metabolismo , Intervalo Livre de Doença , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Humanos , Estudos Prospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The benefit of adjuvant chemotherapy occurs with early initiation, but is commonly delayed due to postoperative complications. Minimally invasive surgery is proven to significantly reduce complications and hospital length of stay. This study compares open versus laparoscopic liver resection in patients requiring adjuvant chemotherapy. METHODS: 120 consecutive patients with metastatic colorectal liver cancer who underwent liver resection between 2007 through 2012 were reviewed from an IRB prospective database. RESULTS: 44 laparoscopic cases were compared to 76 open cases having equivalent resections. Laparoscopic liver resection patients had lower blood loss (276 ml) than patients with open resection (614 ml). Patients with laparoscopy had shorter length of hospital stay (5 days) than patients with open resection (9 days). Patients with laparoscopic resection had a shorter time of chemotherapy initiation postoperatively (24 days v 39 days). Overall complication rates were higher, but statistically insignificant in patients with open resection. CONCLUSIONS: Our data showed that the shorter LOS with laparoscopic major hepatectomies allows earlier initiation of chemotherapy compared to the open group, without jeopardizing surgical margins or extent of resection. SUMMARY: Over the past decade multiple authors have established that, despite occasional longer operating times, laparoscopic liver surgery is associated with reduced blood loss, reduced postoperative morbidity and shorter hospital stay. The purpose of this analysis was to determine if the advantages of a minimally invasive approach correspond to shorter initiation of adjuvant chemotherapy versus an open approach.
Assuntos
Antineoplásicos/uso terapêutico , Neoplasias Colorretais/patologia , Hepatectomia , Laparoscopia , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Hepáticas/cirurgia , Quimioterapia Adjuvante , Esquema de Medicação , Feminino , Humanos , Tempo de Internação , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The multifactorial incidence of infectious complications carries considerable consequences for patients undergoing more extensive surgery with intent to cure metastatic colorectal cancer. Advances in ablation techniques have emerged as an efficacious method in regional control for liver metastasis from colorectal cancer; however, the degree of increased risk of infectious complications when ablation is performed in combination with colon resection has not been defined. METHODS: An analysis of a single institution's prospective database from August 1998 to December 2012 was performed for patients undergoing colon resection. Patients were stratified into a colon resection combined with either microwave ablation (MWA) or radiofrequency ablation (RFA) compared to a colon resection only group. Variables included baseline clinicopathologic data, type of operation, complication grade, and infectious outcome. Fisher exact test, Student t test, and analysis of variance were used to detect significance levels of P values less than .05. RESULTS: A total of 132 patients with colon cancer of various origins were identified. The group of colon resection combined with RFA and/or MWA was 53 patients (34 male:19 female) and was compared to a matched group of 79 patients (40 male:39 female) who underwent colon resection alone. Median age (58 vs 60 years; P = .209), complication rate (60.7% vs 62.5%; P = .722), infection rate (28.7% vs 35.4%; P = 1.0), mean blood loss (352.7 vs 468.4 mL; P = .452), mean blood transfused (1.36 vs .76 U; P = .247), and receipt of neoadjuvant chemotherapy (47.1% vs 51.85%; P = .724) were all similar between the ablation group and colon only group, respectively. Transfusion rate was higher in the ablation group (39.6% vs 18.9%; P = .016). Overall complication rate was 60.6%, with 32.6% infections. One mortality was observed in each group. High-grade (grade, III to V) complications (35.8% vs 18.9%; P = .0112) and liver-specific complications (n = 4; P = .024) were significantly increased in the combined ablation group. CONCLUSIONS: Combining MWA or RFA techniques with colon resection for liver metastasis appears to have similar infectious and overall complication rates when compared to performing an isolated resection of the primary colon cancer alone, although there may be a higher degree of complication seen in the more aggressive approach for curative intent in patients with colorectal liver metastasis.
Assuntos
Ablação por Cateter , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Hepatectomia , Infecções/epidemiologia , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Hepatic artery lymph node (HALN) metastasis in pancreatic adenocarcinoma reportedly confers a survival disadvantage. This has led some authors to propose it as an indicator against pancreaticoduodenectomy (PD). METHODS: Consecutive patients who underwent PD during 2002-2012 were identified from the University of Louisville prospective hepatopancreaticobiliary database. Overall survival (OS) and disease-free survival (DFS) were estimated using Kaplan-Meier analysis. The log-rank test and multivariate Cox proportional hazards regression were used in further analyses. RESULTS: A total of 420 patients underwent PD during the period of study, of whom 197 had lymph node (LN) metastasis. Among these, 41 (20.8%) patients had disease-positive HALNs. The HALN was the only site of LN metastasis in only three of the 247 patients (1.2%). Median follow-up was 18.5 months (interquartile range: 4.1-28.2 months). Median OS and DFS were 22.7 months [95% confidence interval (CI) 19.0-26.3] and 12.6 months (95% CI 10.2-15.2). There was no significant difference in median OS between HALN-positive patients (18.4 months, 95% CI 12.3-24.0) and HALN-negative patients (19.7 months, 95% CI 16.7-22.6) (P = 0.659). On multivariate analysis, the hazard ratio (HR) of death was highest among patients with an LN ratio of >0.2 (HR 1.2, 95% CI 1.1-1.29; P = 0.012) followed by those with poorly differentiated histology (HR 1.09, 95% CI 1.04-1.11; P = 0.029). CONCLUSIONS: In pancreatic adenocarcinoma patients with LN disease, survival after PD is comparable regardless of HALN status. Therefore, HALN-positive disease should not preclude the performance of PD.
Assuntos
Adenocarcinoma/secundário , Adenocarcinoma/cirurgia , Linfonodos/patologia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia , Adenocarcinoma/mortalidade , Bases de Dados Factuais , Intervalo Livre de Doença , Artéria Hepática , Humanos , Estimativa de Kaplan-Meier , Kentucky , Excisão de Linfonodo , Linfonodos/cirurgia , Metástase Linfática , Análise Multivariada , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Seleção de Pacientes , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Hepatic resection is associated with substantial morbidity and resource use. To contain costs and improve outcomes, recent health care regulations focus on reducing hospital readmissions while using readmission rates as a quality measure. The goal of this investigation was to characterize the incidence, patterns, and risk factors for readmission after resection for hepatocellular carcinoma. STUDY DESIGN: Patient demographics, operative factors, and perioperative outcomes of 245 patients undergoing hepatic resection at an academic center from 2000 to 2012 were reviewed retrospectively. Factors associated for readmission within 90 days of operation were identified through univariate and multivariate logistic regression analysis. RESULTS: Forty-six patients (18.7%) required hospital readmission. Univariate analysis identified American Society of Anesthesiologists class, preoperative Model for End-stage Liver Disease score and total bilirubin, preexisting vascular disease, acute renal failure, bile leak, peak postoperative total bilirubin, and intraabdominal infection as factors associated with readmission. Intraabdominal infection, postoperative renal failure, and a history of vascular disease were found to be significant on multivariate analysis. Overall, intraabdominal infection was the strongest predictor for readmission. CONCLUSION: Early readmission after hepatectomy remains relatively common. Postoperative complications and patient comorbidities are the dominant factors in readmission, and we must be mindful of those patients at increased risk for readmission.
Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia , Neoplasias Hepáticas/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Malignant blue nevus (MBN) is a rare melanocytic lesion and controversy exists whether it is a melanoma or a unique entity. We sought to establish clinical behavior using a large national registry. All patients with MBN and melanoma from 1973 to 2008 were identified in the Surveillance Epidemiology and End Results tumor registry. We performed comparative and survival analysis among the two tumor types. A total of 228,038 patients were identified (227,986 with melanoma and 52 with MBN). The mean age was 57.7 years. Both lesions had similar age of presentation (55.8 vs 55.7 years, P = 0.527), sex (male 50 vs 55%, P = 0.44), and nodal positivity rate (9.6 vs 5.4%, P = 0.22). MBNs were more likely to be nonwhite (11.8 vs 1.6%, P < 0.0001) and present with metastatic disease (15.2 vs 4%, P = 0.0028). MBN and melanoma had a similar survival (264 vs 240 months, P = 0.78) and remained similar when stratified by race (264 vs 242 months, P = 0.99) and stage (264 vs 256 months, P = 0.83). This is the largest study to date demonstrating similar clinical behavior and survival between patients with MBN and those with melanoma. We believe MBN is a variant of melanoma and suggest using a similar treatment algorithm as that of melanoma.
Assuntos
Melanoma/patologia , Nevo Azul/patologia , Neoplasias Cutâneas/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Metástase Linfática , Masculino , Melanoma/epidemiologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Nevo Azul/epidemiologia , Modelos de Riscos Proporcionais , Sistema de Registros , Programa de SEER , Neoplasias Cutâneas/epidemiologia , Análise de Sobrevida , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: The number of osteopathic physicians is increasing as is the number applying to allopathic general surgery residency programs. A lack of knowledge of osteopathic schooling leads to a potential applicant bias in favor of allopathic applicants, but the 2 groups have not been compared head to head. DESIGN: Applications over a 6-year period to an allopathic general surgery residency program were reviewed. Demographics, examination scores, employment, education, and research experience were catalogued into a database. Allopathic applicants were compared with osteopathic applicants utilizing statistical analysis. SETTING: A university teaching hospital. PARTICIPANTS: Allopathic and osteopathic applicants to an allopathic general surgery residency program. RESULTS: A total of 1290 applications were reviewed; 1155 allopathic and 135 osteopathic applications. Other than race, the 2 cohorts are similar in age, gender, and citizenship. The groups are not significantly different with regard to the number of letter of recommendations, volunteer activities, scholarly works, and advanced degrees. Graduates of both proceed directly to residency. A significantly higher percentage of allopathic graduates reported their United States medical licensing examination (USMLE) scores, yet when osteopaths released their USMLE transcript, they scored significantly higher on the USMLE Step 1 examination and required fewer attempts to pass. These differences do not apply to the USMLE Step 2 examination. CONCLUSIONS: No single screening tool exists for selecting a successful general surgery resident. We are seeing increased numbers of osteopathic applicants. Many criteria used to evaluate applicants do not apply to osteopathic applicants, but our comparison of common selection variables on the Electronic Residency Application Service (ERAS) application did not demonstrate an overall difference. While our analysis demonstrated a statistically higher USMLE Step 1 score by osteopathic applicants, they may only self-report favorable data.
Assuntos
Cirurgia Geral/educação , Internato e Residência/estatística & dados numéricos , Medicina Osteopática/educação , Adulto , Feminino , Humanos , Candidatura a Emprego , Masculino , Estudos Retrospectivos , Faculdades de Medicina , Fatores de TempoRESUMO
BACKGROUND: The purpose of this study was to evaluate the 10-year outcome of patients presenting with asymptomatic moderate carotid artery stenosis, and to determine which factors correlate with progression of disease to stroke or revascularization. METHODS: A retrospective review of all new patients presenting with asymptomatic moderate carotid artery stenosis from July 1998 to December 2001 was undertaken. Patients were consecutively identified and included by using duplex ultrasonography to identify moderate carotid disease. Variables were recorded for all patient encounters through June 2010. The primary end point was occurrence of ipsilateral cerebrovascular stroke or revascularization event (SORE). Statin therapy and angiotensin blockade (STAB) were categorized as follows: STAB(0)-medical treatment with neither statin therapy nor angiotensin blockade, STAB(1)-treatment with only one of the two, STAB(2)-treatment with both. An amortized cost model analyzed the cost of SORE-free survival. RESULTS: Over a 42-month period, 468 carotids in 366 patients with an average age of 69.0 ± 8.7 years were evaluated. Over a mean follow-up of 6.6 ± 2.7 years, SORE occurred in 150 (32.1%) carotid arteries. Hyperlipidemia was predictive of SORE (hazard ratio [HR]: 1.543, 95% confidence interval [CI]: 1.053-2.262, P = 0.03). Medical therapies protective against SORE were beta-blockade (HR: 0.612, 95% CI: 0.435-0.861, P < 0.05), STAB(1) (HR: 0.487, 95% CI: 0.336-0.706, P < 0.01), and STAB(2) (HR: 0.149, 95% CI: 0.089-0.248, P < 0.01). At 10 years, SORE-free survival in STAB(2) was 82.7% ± 4.6%, STAB(1) was 56.3% ± 5.0%, and STAB(0) was 29.3% ± 5.4% (P < 0.01). The cost per SORE-free year in STAB(2) was $1,695.40 ± $275.60, STAB(1) was $3,916.80 ± $605.44, and STAB(0) was $4,126.40 ± $427.23 (P < 0.01). CONCLUSION: These data demonstrate the clinical and financial advantage of using both statin therapy and angiotensin pathway blockage in patients with asymptomatic moderate carotid artery stenosis.
Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Estenose das Carótidas/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Idoso , Angioplastia , Bloqueadores do Receptor Tipo 1 de Angiotensina II/efeitos adversos , Bloqueadores do Receptor Tipo 1 de Angiotensina II/economia , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/economia , Doenças Assintomáticas , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/economia , Estenose das Carótidas/mortalidade , Estenose das Carótidas/cirurgia , Análise Custo-Benefício , Progressão da Doença , Intervalo Livre de Doença , Custos de Medicamentos , Quimioterapia Combinada , Endarterectomia das Carótidas , Feminino , Custos de Cuidados de Saúde , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , North Carolina , Estudos Retrospectivos , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
BACKGROUND AND OBJECTIVES: Apocrine adenocarcinoma is a rare neoplasm. There is a paucity of data on demographics and survival with no clear consensus on management of at risk lymph nodes, therefore, we analyzed a large cohort of patients identified via a national tumor registry. METHODS: Patients ages 17-91 from 1973 to 2006 were identified in the SEER registry and excluded breast and non-cutaneous neoplasms. Data analyzed included basic demographics, survival, surgical therapy, and stage. RESULTS: A total of 186 patients with apocrine adenocarcinoma were identified. The median age was 67 years, 76% were white and there was an equal distribution of males and females. The most common site was trunk (53%) followed by head and neck (35%). Surgery was performed on most patients (96%), either excision (50%) or wide excision (30%). Lymph node metastases were present in 69% patients undergoing node surgery. Median overall survival was 51.5 months. Positive lymph node status (P = 0.006) and metastatic disease (P < 0.001) were associated with diminished overall survival. CONCLUSIONS: Cutaneous apocrine adenocarcinoma is a rare neoplasm. Excision is standard treatment. The most important predictor of survival in localized disease is lymph node status; therefore, sentinel lymph node biopsy could be considered in management of this disease.
Assuntos
Adenocarcinoma/epidemiologia , Adenocarcinoma/mortalidade , Glândulas Apócrinas , Excisão de Linfonodo , Neoplasias Cutâneas/epidemiologia , Neoplasias Cutâneas/mortalidade , Adenocarcinoma/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Linfonodos/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Programa de SEER , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/cirurgia , Taxa de Sobrevida , Neoplasias das Glândulas Sudoríparas/epidemiologia , Neoplasias das Glândulas Sudoríparas/mortalidade , Neoplasias das Glândulas Sudoríparas/cirurgia , Adulto JovemRESUMO
The incidence of new onset or worsening diabetes is surprisingly low in patients after partial pancreatectomy for cancer, leading us to question what factors predict diminished glycemic control in those undergoing resection. All patients undergoing pancreatectomy for cancer at a large, rural university teaching hospital between 1996 and 2010 were identified. The incidence of new onset, or worsening, existing diabetes was determined based on pre and postoperative medication requirement. Univariate analysis was undertaken to identify factors that predict worsened glycemic control. One hundred and one (1 total, 79 Whipple, 21 distal) patients were identified, 41 per cent of which had preexisting diabetes. Nearly half of existing diabetics manifested an increased medication requirement prior to their cancer diagnosis. New onset diabetes occurred in 20 per cent of postoperative patients. Of established diabetics, 34 per cent had either improved glycemic control (9/41) or were cured (5/41) despite the reduction of islet cell mass that occurred with surgery. On univariate analysis, only prolonged hospitalization was associated with worsened glycemic control. Diminished glycemic control is a frequent presenting symptom of pancreatic cancer. Worsened or new onset diabetes is associated with length of stay, which can be influenced by a number of factors including complications and comorbidities.
Assuntos
Glicemia/análise , Diabetes Mellitus/fisiopatologia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Idoso , Análise de Variância , Estudos de Coortes , Intervalos de Confiança , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/cirurgia , Progressão da Doença , Feminino , Seguimentos , Hospitais Universitários , Humanos , Hipoglicemiantes/uso terapêutico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/diagnóstico , Período Pós-Operatório , Estudos Retrospectivos , Medição de Risco , Resultado do TratamentoRESUMO
Most case series describing peritoneovenous (PV) shunts for malignant ascites include both LeVeen and Denver shunts. Conclusions based on these studies are no longer clinically relevant since the LeVeen shunt has been discontinued. The purpose of this study was to identify outcomes specific to Denver shunts to establish expected results in the modern era. Case series describing PV shunts for malignant ascites between 1980 and 2008 were identified through a keyword PUBMED search. Whenever possible, results attributable to Denver shunts were abstracted and analyzed. Nineteen series describing 341 patients undergoing 353 Denver PV shunts for malignant ascites were identified. The primary indications for PV shunts were unspecified or cancers of unknown origin (40%), ovarian cancer (16%), and pancreatic cancer (8%). Primary patency averaged 87 ± 57 days. Seventy-four per cent of patients died with functioning shunts. Complications occurred in 38% of patients including occlusion (24%) and disseminated intravascular coagulation (9%). Average survival of all patients was 3.0 ± 1.7 months and shunts provided effective palliation in 75.3%. One and a half per cent of 133 patients who had autopsies were reported to have hematologic dissemination. These results are not statistically different than overall results reported for both shunts combined or LeVeen shunts alone. Studies that report combined outcomes with Denver and LeVeen shunts for malignant ascites are neither negatively, nor positively influenced by one specific shunt. Expectations following PV shunting for malignant ascites do not have to be revised because LeVeen shunts are no longer available.
Assuntos
Ascite/patologia , Ascite/cirurgia , Causas de Morte , Neoplasias/complicações , Cuidados Paliativos/métodos , Derivação Peritoneovenosa/métodos , Ascite/etiologia , Ascite/mortalidade , Feminino , Humanos , Masculino , Neoplasias/patologia , Neoplasias/cirurgia , Derivação Peritoneovenosa/mortalidade , Prognóstico , Medição de Risco , Análise de Sobrevida , Fatores de TempoRESUMO
BACKGROUND: Peripheral thrombolysis is an indispensible tool in the treatment of occlusive peripheral vascular disease (PVD). However, the use of intravascular thrombolytic agents carries a significant risk of morbidity and mortality. The aim of this study is to review a contemporary series of patients treated with catheter-directed thrombolytics in the treatment of occlusive PVD. METHODS: A retrospective analysis was performed reviewing all patients who underwent catheter-directed thrombolytic therapy for PVD with recombinant tissue plasminogen activator (rt-PA) between 2005 and 2008. Data included clinical and demographic variables potentially associated with endpoints of technical success, hemorrhagic complications, and death. Data were analyzed with univariate and multivariate measures. Significance was assigned with p <0.05. RESULTS: Over the 36-month study, 125 thrombolytic procedures were performed. Indication for treatment was occlusive thrombus in native artery (49 cases, 37.6%), vein (13 cases, 10.4%), or arterial bypass graft (63 cases, 49.6%). Twenty three cases (14.3%) used ultrasound-assisted catheter technology. Mean patient age was 57.9 +/- 1.1 years. Technical success was achieved in 82% of cases. Mean rt-PA dose was 47.3 +/- 1.4 mg (13.5 +/- 4.5 mg with ultrasound assisted catheter technology). Hemorrhagic complications occurred in 22.4% of patients with a 5.6% stroke rate. Intracranial hemorrhage (ICH) correlated with poor hypertensive control (systolic blood pressure >160 mmHg; OR, 13.67; CI, 1.59-117.68; p = 0.006) and advanced age (>80 years; OR, 9.04; CI, 1.40-58.57, p = 0.049). Hemorrhagic complications (including minor access site hematomas) correlated with poor hypertensive control (systolic blood pressure >180 mmHg; OR, 3.48; CI, 1.22-9.94; p = 0.021) and in patients with congestive heart failure (OR, 3.26; CI, 1.09-9.76; p = 0.036). Overall mortality occurred in 7 patients (5.6%), 4 as a result of hemorrhagic complications. Correlates of mortality were patients with diabetes mellitus (OR, 8.85; CI, 1.62-48.26; p = 0.003), end stage renal disease (OR, 15.33; CI, 2.07-113.39; p < .001) and congestive heart failure (OR, 6.06; CI, 1.22-30.13; p = .014). Serum fibrinogen levels, pre-procedural hypertension, and rt-PA dosage did not correlate with hemorrhagic complication or death. CONCLUSION: Peripheral thrombolysis with catheter-based technologies has a high incidence of technical success. However, the procedure continues to carry a significant complication rate. This study emphasizes the importance of periprocedural hypertensive control and identifies subgroups of patients at risk of untoward complications. On the basis of these data, the authors advocate stricter blood pressure parameters in patients undergoing peripheral thrombolysis.
Assuntos
Arteriopatias Oclusivas/tratamento farmacológico , Cateterismo Periférico , Fibrinolíticos/efeitos adversos , Hipertensão/complicações , Terapia Trombolítica/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Trombose Venosa/tratamento farmacológico , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/fisiopatologia , Pressão Sanguínea , Distribuição de Qui-Quadrado , Fibrinolíticos/administração & dosagem , Hematoma/induzido quimicamente , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hemorragias Intracranianas/induzido quimicamente , Modelos Logísticos , Pessoa de Meia-Idade , North Carolina , Razão de Chances , Proteínas Recombinantes/efeitos adversos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/induzido quimicamente , Terapia Trombolítica/mortalidade , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento , Ultrassonografia de Intervenção , Trombose Venosa/complicações , Trombose Venosa/fisiopatologiaRESUMO
BACKGROUND: Foregut diversion and weight loss have been proposed as potential mechanisms for resolution of type II diabetes mellitus (T2DM) observed in patients undergoing gastric bypass for obesity. To support or refute the role of the foregut, we analyzed glycemic control in T2DM patients before and after foregut bypass for reasons other than morbid obesity. STUDY DESIGN: Using ICD9/CPT codes, we identified patients undergoing Roux-en-Y gastrojejunostomy (RY) or Billroth II (BII) reconstruction over 10 years. Fasting blood glucose, insulin or oral diabetic agent requirement, and body mass index (BMI) before and after surgery were tabulated and compared using the Student's t-test. Linear regression was applied to determine specific factors predictive of resolution or improvement in glycemic control including age, duration of diabetes, antidiabetic regimen, type of operation, and surgical indication. RESULTS: Between 1996 and 2006, we identified 24 patients with T2DM out of a cohort of 209 who underwent either RY (12 of 24) or BII reconstruction (12 of 24) for cancer or peptic ulcer disease and survived more than 30 days after operation. Of this group, 75% were overweight (18 of 24 with BMI < 30 kg/m(2)) and 25% were class I morbidly obese (6 of 24 with BMI 30 to 35 kg/m(2)). Seventeen patients (71%) had either complete resolution (7 of 24 or 29%) or significant reduction (10 of 24 or 42%) in medication requirements; 7 patients (29%) did not have any improvement. Logistic regression failed to identify specific factors predicting improved glycemic control. CONCLUSIONS: Complete resolution of T2DM in patients undergoing duodenal diverting surgery occurs in about one-third of nonobese patients. Improved glycemic control occurs in more than two-thirds and cannot be explained by surgically related weight loss alone. Surgical cure of T2DM may be possible in carefully selected nonobese patients.
Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Diabetes Mellitus Tipo 2/fisiopatologia , Derivação Gástrica , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Redução de Peso/fisiologia , Idoso , Idoso de 80 Anos ou mais , Glicemia/metabolismo , Índice de Massa Corporal , Estudos de Coortes , Diabetes Mellitus Tipo 2/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/metabolismo , Obesidade/cirurgia , Estudos Retrospectivos , Estômago/fisiopatologiaRESUMO
INTRODUCTION: This study hypothesized that preoperative statin therapy would have a protective effect on patients undergoing elective abdominal aortic aneurysm (AAA) repair and that the risk-reduction effect of these agents would result in a reduction in subsequent total hospital costs. METHODS: All patients who underwent an elective endovascular AAA repair (EVAR) or open AAA repair (OAR) between 2004 and 2007 were retrospectively reviewed. Clinical end points included postoperative days, length of hospital stay, postoperative complications (myocardial infarction, stroke, renal failure, hemorrhage, pneumonia, urinary tract infection, wound infection), and 30-day mortality. The financial end point was total hospital cost associated with the procedure. RESULTS: We identified 401 patients, consisting of 173 EVAR patients (43%) and 228 OAR (57%). Despite a higher Society for Vascular Surgery risk score, the EVAR statin cohort had significantly reduced postoperative days (1.9 +/- 0.2 vs 2.3 +/- 0.3, P < .05) and hospital length of stay (2.3 +/- 0.3 vs 2.8 +/- 0.4, P < .05) compared with the nonstatin EVAR cohort. Postoperative complications (4.4% vs 14.7%, P < .05) and the mortality rate (0.0% vs 5.9%, P < .05) were significantly decreased in the OAR statin cohort compared with the nonstatin OAR cohort and trended to be decreased in the EVAR statin group. Statin therapy translated into a lower total cost per patient of $3,205 for EVAR and $3,792 for OAR (P < .05). CONCLUSION: With respect to both clinical outcome measures and subsequent resource utilization, statin therapy is associated with a beneficial effect in patients undergoing elective AAA repair. These data suggest that preoperative statin therapy should be an integral part of the risk optimization for patients undergoing AAA repair.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Atenção à Saúde/estatística & dados numéricos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Avaliação de Processos e Resultados em Cuidados de Saúde , Idoso , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/mortalidade , Distribuição de Qui-Quadrado , Atenção à Saúde/economia , Custos de Medicamentos , Procedimentos Cirúrgicos Eletivos , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/economia , Tempo de Internação , Modelos Logísticos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: This study compares internal carotid artery (ICA) mean stump pressures (SPs) with cerebral oximetry monitoring during carotid endarterectomy (CEA). METHODS: A total of 104 consecutive patients undergoing CEA under general anesthesia (GA) during a 10-month period were prospectively evaluated. Baseline and postcarotid clamp regional cerebral oxygen saturation (rSO(2)) and mean ICA SPs were measured. Demographic, surgical, and medical variables were recorded for each case. RESULTS: There were no postoperative strokes. Thirteen patients were excluded because of incomplete data. Of the 40 patients who had <10% drop in rSO(2), 6 had SP <40 mm Hg. Regional cerebral oxygen saturation with a 15% saturation drop threshold was 76.3% sensitive and 81.1% specific in detecting patients with SP <40 mm Hg. With a threshold of 20% drop, sensitivity and specificity were 57.9% and 86.8%, respectively. CONCLUSIONS: Relative drop in rSO( 2) is neither sensitive nor specific in detecting patients with mean SP <40 mm Hg. These data do not support the use of cerebral oximetry as the sole monitoring modality during carotid endarterectomy under GA.
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Pressão Sanguínea , Isquemia Encefálica/diagnóstico , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Circulação Cerebrovascular , Endarterectomia das Carótidas , Monitorização Intraoperatória/métodos , Oximetria , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Determinação da Pressão Arterial , Isquemia Encefálica/fisiopatologia , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/fisiopatologia , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
Mortality after complex surgical procedures has been shown to be inversely related to hospital volume. The purpose of this study was to determine whether these findings are applicable to radiologic and surgical procedures for complicated portal hypertension. The Agency for Healthcare Administration for the State of Florida database was queried to determine outcomes after transjugular intrahepatic stent shunts (TIPS) or surgical shunts from 2000 to 2003. A total of 1486 patients underwent either TIPS (1321) or surgical shunts (165). Natural breakpoints occurred at two and six procedures per year were correlated with survival for surgical shunts but not TIPS. Overall mortality was not different between TIPS and surgical shunts (11.0 vs. 12.7%, P = 0.51); however, the cost of TIPS was significantly lower (62,000 +/- 58.5 vs. 107,000 +/- 97.8, P < 0.001) as well as the length of hospitalization (9 +/- 9.0 days vs. 15 days +/- 12.6 days, P < 0.001). Surgical procedures for complicated portal hypertension are rapidly being replaced by TIPS. Like with other complex procedures, outcomes are related to hospital volume.
Assuntos
Hipertensão Portal/mortalidade , Hipertensão Portal/cirurgia , Avaliação de Resultados em Cuidados de Saúde , Derivação Portossistêmica Cirúrgica/mortalidade , Derivação Portossistêmica Cirúrgica/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Adulto , Bases de Dados Factuais , Feminino , Florida/epidemiologia , Mortalidade Hospitalar , Humanos , Hipertensão Portal/complicações , Masculino , Pessoa de Meia-Idade , Derivação Portossistêmica Cirúrgica/economia , Derivação Portossistêmica Transjugular Intra-Hepática/economia , Derivação Portossistêmica Transjugular Intra-Hepática/mortalidade , Derivação Portossistêmica Transjugular Intra-Hepática/estatística & dados numéricos , Análise de SobrevidaRESUMO
Safe thyroid surgery requires meticulous hemostasis. The objective of the current study is to compare the effectiveness and safety of ultrasonic dissection (UD) and electronic vessel sealing (EVS) in patients undergoing thyroidectomy. A retrospective analysis of a prospectively maintained database was performed. Between January 1, 2007 and January 25, 2008, hemostasis was achieved using EVS (LigaSure Precise, Valleylab, Boulder, CO). Since January 25, 2008, hemostasis has been achieved using UD (Harmonic Focus, Ethicon Endo-Surgery, Cincinnati, OH). Operative time, estimated blood loss, gland weight, and postoperative complications were compared. Differences were analyzed using unpaired t test and Chi square with significance assigned P < 0.05. Seventy-four patients underwent total thyroidectomy (EVS n = 59, UD n = 15). Operative time (EVS 115.0 +/- 38.3 min, UD 88.0 +/- 14.0 min, P = 0.012) was significantly decreased in the UD group compared with the EVS group. There were no significant differences in mean age (EVS 50.4 +/- 13.9 years, UD 49.1 +/- 15.6 years), gender distribution (EVS 78% female, UD 87% female), estimated blood loss (EVS 49.4 +/- 44.7 mL, UD 47.0 +/- 70.4 mL), and gland weight (EVS 67.4 +/- 66.4 gm, UD 41.3 +/- 26.6 gm). Analysis of complications, including hematoma, hypocalcemia, and recurrent laryngeal nerve palsy showed no significant difference. Based on the current analysis, ultrasonic dissection is a safe method of hemostasis for thyroid surgery. Its use decreases operative time when compared with electronic vessel sealing.
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Perda Sanguínea Cirúrgica/prevenção & controle , Eletrocoagulação/métodos , Hemostasia Cirúrgica/métodos , Hemorragia Pós-Operatória/prevenção & controle , Tireoidectomia/métodos , Terapia por Ultrassom/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION: Patients with paraesophageal hernias often present secondary to chronic symptomatology. Infrequently, acute intestinal ischemia and perforation can occur as a consequence of paraesophageal hernias with potentially dire consequences. CASE PRESENTATION: An 86-year-old obtunded male presented to the emergency department with hypotension and severe back and abdominal pain. An emergency abdominal CT scan was ordered with a presumptive diagnosis of ruptured abdominal aortic aneurysm. CT topograms revealed extensive free intra-abdominal air and herniated abdominal viscera into the right hemithorax. Prior to completion of the CT study, the patient sustained a cardiopulmonary arrest. Surgery was consulted, but the patient was unable to be revived. Post-mortem examination revealed gross contamination within the abdomen and a giant, incarcerated, hiatal hernia with organoaxial volvulus and ischemic perforation. CONCLUSION: Current recommendations call for prompt repair of giant hiatal hernias before they become symptomatic due to the increased risk of strangulation. Torsion of the stomach in large hiatal hernias frequently leads to a fatal complication such as this warranting elective repair as soon as possible.
RESUMO
A case of substantial debris captured by an embolic protection device placed in a patient's transplanted renal artery during common iliac artery angioplasty and stent placement is presented. To the authors knowledge, no previous literature exists pertaining to renal artery protection in patients with a history of a heterotopic renal transplant undergoing aortoiliac endovascular interventions.