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BACKGROUND: Percutaneous cholecystostomy (PCT) is a safe method of gallbladder drainage in the setting of severe or complicated acute cholecystitis (AC), particularly in patients who are high-risk surgical candidates. Small case series suggest that PCT aids resolution of acute cholecystitis in up to 90% of patients. However, reluctance is observed in utilising PCT more frequently, due to concerns that we are committing comorbid patients to an interval surgical procedure for which they may not be suitable. AIM: The aim of this study was to assess the clinical and survival outcomes of PCT use, with particular emphasis on a subgroup of patients who did not proceed to cholecystectomy. METHODS: A retrospective analysis was performed of all patients with severe acute cholecystitis who required PCT insertion in a tertiary referral hospital from 2010 to 2015. Patient demographics and clinical data including systemic inflammatory response (SIRS) scores at presentation, readmissions and clinical and survival outcomes were analysed. Statistical analysis was performed using SPSS v.22 and GraphPad Prism v.7. RESULTS: In total, 157 patients (59% males) with AC underwent PCT insertion during the study period. Median age at presentation was 71 years (range 29-94). A median SIRS score of 3 was noted at presentation. Patients required a median of two cholecystostomy tube changes/replacements (range 1-10) during treatment. Transhepatic tube placement was the preferred approach (69%) with 31% of tubes being placed via transabdominal approach. Only 55% proceeded to interval cholecystectomy. Of the 70 patients treated with PCT alone, their median age was 75 years. In this subgroup, only 12.9% (n = 9) developed recurrent biliary sepsis necessitating readmission following initial resolution of symptoms and tube removal. All episodes of recurrent biliary sepsis presented within 6 months of index presentation, and definitive PCT removal in this group was performed at a median of 3 months. No difference in survival was observed between both groups. CONCLUSION: Almost 90% of patients with AC who are managed definitively with a PCT will recover uneventfully without recurrent sepsis following PCT removal. This is a viable option for older, comorbid patients who are unfit for surgical intervention and is not associated with significantly increased mortality.
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Colecistite Aguda , Colecistostomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia , Colecistite Aguda/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Optimal management of the endometrium in patients with oestrogen receptor-positive breast cancer taking extended tamoxifen therapy (for 10 years) remains uncertain. A meta-analysis was performed to determine the cumulative risk ratio (RR) for endometrial malignancy following extended compared with standard tamoxifen treatment. A systematic review was undertaken to identify whether routine endometrial surveillance in patients receiving tamoxifen is associated with earlier detection and reduced incidence of endometrial malignancy. METHODS: Two independent searches were undertaken in the Cochrane Library, PubMed and MEDLINE. A meta-analysis was performed of RCTs reporting on endometrial malignancy risk in extended tamoxifen therapy. A systematic review included prospective studies investigating the benefit of endometrial surveillance during tamoxifen therapy. RESULTS: Four RCTs reported on endometrial risk in extended tamoxifen therapy. The cumulative risk of endometrial malignancy increased twofold from 1·5 to 3·2 per cent with extended therapy compared with the standard 5 years of tamoxifen (RR 2·29, 95 per cent c.i. 1·60 to 3·28; P < 0·001). Four studies analysed the value of endometrial screening in 5-year cohorts. Endometrial cancer rates of up to 2 per cent were reported, which is higher than rates in the large extended tamoxifen trials. CONCLUSION: Extended adjuvant tamoxifen is associated with an increase in endometrial cancer. No clear benefit has been shown for routine endometrial surveillance in asymptomatic patients on tamoxifen therapy.
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Neoplasias do Endométrio/tratamento farmacológico , Tamoxifeno/uso terapêutico , Antineoplásicos Hormonais/uso terapêutico , Progressão da Doença , Neoplasias do Endométrio/epidemiologia , Feminino , Saúde Global , Humanos , Incidência , Resultado do TratamentoRESUMO
INTRODUCTION: Segmental duodenal resections (DR) have been increasingly performed for the treatment of primary duodenal tumours. The aim of the study is to review the indications for, clinical and operative details, and outcomes of patients undergoing elective DR. MATERIAL AND METHODS: We retrospectively reviewed all patients who underwent elective segmental DR for the treatment of primary duodenal tumours, at a single institution between January 2007 and December 2013. Demographic data, clinical presentation, preoperative investigations, operative details, postoperative complications/mortality and histopathological results were recorded. RESULTS: In the study period, 11 duodenal resections were performed (7 male, median age 61 years). Thirty-six percent of the patients presented with anaemia. Surgical resection included two or more segments in seven patients. The most frequently resected part of the duodenum was segment 3 (n = 7). Median operative time was 191 min and blood loss was 675 ml. End-to-end and end-to-side anastomoses were performed in equal numbers. The pathology of resected specimens included adenocarcinoma (n = 4), gastrointestinal stromal tumour (GIST) (n = 1), adenoma (n = 5) and lymphoma (n = 1). Median hospital stay was 14 days. Overall, 30-day morbidity rate was 82% (78% Clavien 2 or less). CONCLUSIONS: Segmental duodenal resection is a safe and effective surgical technique for the resection of primary duodenal tumours.
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Adenocarcinoma/cirurgia , Adenoma/cirurgia , Neoplasias Duodenais/cirurgia , Tumores do Estroma Gastrointestinal/cirurgia , Idoso , Idoso de 80 Anos ou mais , Neoplasias Duodenais/patologia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIM: The optimal surgical approach to the management of colorectal cancer in the setting of hereditary nonpolyposis colorectal cancer (HNPCC) is contentious. While some advocate total colectomy, others perform segmental resection followed by regular endoscopic surveillance. This systematic review evaluates the evidence for segmental colectomy (SC) and total (extended) colectomy (TC) in the management of HNPCC. METHOD: Two major databases (PubMed and Cochrane) were searched using predefined terms. All original articles, published in English, comparing the oncological outcomes of SC and TC in HNPCC patients from January 1950 to July 2013 were included. RESULTS: Eighty-four studies were identified. After applying exclusion criteria, six studies involving 948 patients were included (mean age 47.4 years, 51.8% male). SC was more commonly performed than TC (n = 780; 82.3%). Mean follow-up was 106.5 months. Metachronous high-risk adenomas were detected more often after SC, although the difference was not statistically significant (23.4% vs 9.6%; OR 2.258, P = 0.057). Metachronous cancers occurred more frequently after SC than after TC (23.5% vs 6.8%; OR 3.679, P < 0.005). However, there was no difference in overall survival (90.7% vs 89.8% for SC and TC, respectively; P = 0.085). Only one study reported operative mortality (0% in each group), there was no report of operative morbidity or functional outcome. CONCLUSION: The optimal surgical approach in the management of HNPCC remains unclear. More adenomas and cancers occur after SC than after TC but there certainly is no evidence to suggest that more radical surgery leads to improved survival.
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Adenocarcinoma/cirurgia , Adenoma/cirurgia , Colectomia/métodos , Neoplasias Colorretais Hereditárias sem Polipose/cirurgia , Recidiva Local de Neoplasia/prevenção & controle , Gerenciamento Clínico , Humanos , Procedimentos Cirúrgicos ProfiláticosRESUMO
BACKGROUND: Metastatic tumours of the pancreas are rare and the optimal management of these tumours remains unclear, given the paucity of data existing in the literature. We report our experience of pancreatic metastasectomy. METHODS: Data were reviewed on all patients who underwent pancreatic resection for pathologically confirmed metastatic lesions over a consecutive 7-year period. RESULTS: Seven patients (two men and five women) underwent a pancreatectomy for a metastatic pancreatic tumour. The primary tumours were renal cell carcinoma (n = 3), colorectal carcinoma (n = 2) and leiomyosarcoma (n = 2). There was no operative mortality. Postoperative morbidities occurred in two patients. The median follow-up was 49 months (range 17-76). Overall 1- and 2-year survivals were 100 and 86 %, respectively, with a 2-year disease-free survival of 72 %. CONCLUSIONS: Our series further supports that pancreatic metastasectomy can be performed safely and achieves acceptable survival outcomes.
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Carcinoma de Células Renais/cirurgia , Carcinoma/cirurgia , Neoplasias Colorretais/patologia , Neoplasias Renais/patologia , Leiomiossarcoma/cirurgia , Metastasectomia , Neoplasias Pancreáticas/cirurgia , Idoso , Carcinoma/secundário , Carcinoma de Células Renais/secundário , Intervalo Livre de Doença , Feminino , Humanos , Leiomiossarcoma/secundário , Masculino , Metastasectomia/efeitos adversos , Pessoa de Meia-Idade , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/secundário , Pancreaticoduodenectomia/efeitos adversos , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
AIM: Tumours rarely metastasise to the pancreas. While surgical resection of such metastases is believed to confer a survival benefit, there is limited data to support such management. We present a systematic review of case series of pancreatic metastasectomy and analysis of survival outcomes. METHODS: A literature search was performed using the PubMed and Cochrane databases and the reference lists of relevant articles, searching for sizeable case series of pancreatic metastasectomy with curative intent. Data extracted included basic demographics, histological primary tumour, presentation, operative management, complications and survival, while the MINORS index was used to assess study quality. RESULTS: 18 studies were found which met our inclusion criteria, involving 399 patients. Renal cell carcinoma (RCC) was the commonest malignancy metastasising to the pancreas, responsible for 62.6% of cases, followed by sarcoma (7.2%) and colorectal carcinoma (6.2%). While survival data was not uniformly reported, the median survival post-metastasectomy was 50.2 months, with a one-year survival of 86.81% and five-year survival of 50.02%. Median survival for RCC was 71.7 months with 70.4% five-year survival. Median survival was similar in patients with synchronous and metachronous pancreatic metastases, but patients with additional extrapancreatic metastases had a significantly shorter survival than patients with isolated pancreatic metastases (26 versus 45 months). Study quality was poor, with a median MINORS score of 10/16. CONCLUSIONS: Within the limitations of a review of non-randomised case series, it would appear that pancreatic metastasectomy confers a survival benefit in selected patients. Better evidence is required, but may prove difficult to acquire.
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Metastasectomia , Pancreatectomia , Neoplasias Pancreáticas/secundário , Neoplasias Pancreáticas/cirurgia , Carcinoma/secundário , Carcinoma/cirurgia , Carcinoma de Células Renais/secundário , Carcinoma de Células Renais/cirurgia , Neoplasias Colorretais/patologia , Humanos , Neoplasias Renais/patologia , Neoplasias Pancreáticas/mortalidade , Sarcoma/secundário , Sarcoma/cirurgia , Análise de Sobrevida , Resultado do TratamentoRESUMO
Up to 3.2% of patients with testicular germ cell tumours represent with late-relapsing disease. Aggressive surgical resection confers the greatest chance of cure in this patient group. We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein. Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus. This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.
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The aim of this research was to compare the accuracy of urinary protein/creatinine ratio (PCR) and albumin/creatinine ratio (ACR) in defining optimal cut-off points to rule-out significant proteinuria (>300 mg/24 h) in pregnancy. The secondary outcome measure was to determine the investigation of choice to evaluate proteinuria used by maternity units in the UK. PCR and ACR were calculated on first (PCR1, ACR1) void urine samples of the 24-hour urinary protein collection (24UP). Sensitivity and specificity was calculated for different cut-off points for PCR1 and ACR1 to rule-out significant proteinuria. An online survey was sent to RCOG members questioning them on their investigation of choice to evaluate proteinuria. We concluded from our results that both PCR and ACR are good rule-out tests for significant proteinuria in pregnancy using cut-off points of <20 mg/mmol and <2.5 mg/mmol. PCR is the investigation of choice in 56% of UK units studied.
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Programas de Rastreamento/métodos , Complicações na Gravidez/diagnóstico , Proteinúria/diagnóstico , Creatinina/urina , Feminino , Humanos , Gravidez , Complicações na Gravidez/urina , Estudos Prospectivos , Proteinúria/urina , Sensibilidade e EspecificidadeRESUMO
Obesity is associated with a variety of weight-related metabolic comorbidities. Bariatric surgery (metabolic/gastrointestinal surgery) not only achieves significant and sustainable weight loss, but also induces extraordinary effects on nearly all obesity-related comorbidities, particularly remission of type 2 diabetes mellitus (T2DM). The mechanisms underlying such effects are slowly being elucidated, and it appears that the metabolic benefits of bariatric surgery are not only attributable to weight loss, but there are also weight independent mechanisms at play. This article outlines the metabolic effects of the most commonly performed bariatric procedures, with a particular emphasis on how they affect glucose metabolism and T2DM.
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Cirurgia Bariátrica/métodos , Diabetes Mellitus Tipo 2/cirurgia , Hiperglicemia/complicações , Obesidade/cirurgia , Redução de Peso/fisiologia , Diabetes Mellitus Tipo 2/complicações , Humanos , Hiperglicemia/sangue , Metanálise como Assunto , Obesidade/complicaçõesRESUMO
MiRNAs are a class of short, endogenous, single-stranded RNA molecules that play a role in the regulation of gene expression. They have been shown to modulate a number of cellular processes including cell differentiation, growth and apoptosis and as a result have been implicated in carcinogenesis. They are detectable in tumour tissue, and altered expression levels have been identified in various cancer types. Of interest, miRNAs have recently been detected and identified to be dysregulated in the circulation of patients with breast cancer. The fact that a minimally invasive test can distinguish the presence or absence of disease illustrates the immense potential these molecules hold as predictive markers. This review serves to identify those systemic miRNAs that are upregulated or downregulated in malignancy and how treatment impacts on their circulating levels. In addition, this review questions the source of these small molecules in the bloodstream and how they may possibly play a role in the future detection of cancer as either prognostic or predictive markers.
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Biomarcadores Tumorais/genética , MicroRNAs/genética , Neoplasias/diagnóstico , Neoplasias/genética , Biomarcadores Tumorais/sangue , Humanos , MicroRNAs/sangue , Ácidos Nucleicos/sangue , Estabilidade de RNARESUMO
BACKGROUND: Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15-20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long-term oncological outcomes in patients found to have a pCR to neoadjuvant CRT. METHODS: Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The systematic review included all original articles reporting long-term outcomes in patients with rectal cancer who had a pCR to neoadjuvant CRT, published in English, from January 1950 to March 2011. RESULTS: A total of 724 studies were identified for screening. After applying inclusion and exclusion criteria, 16 studies involving 3363 patients (1263 with pCR and 2100 without) were included (mean age 60 years, 65·0 per cent men). Some 73·4 per cent had a sphincter-saving procedure. Mean follow-up was 55·5 (range 40-87) months. For patients with a pCR, the weighted mean local recurrence rate was 0·7 (range 0-2·6) per cent. Distant failure was observed in 8·7 per cent. Five-year overall and disease-free survival rates were 90·2 and 87·0 per cent respectively. Compared with non-responders, a pCR was associated with fewer local recurrences (odds ratio (OR) 0·25; P = 0·002) and less frequent distant failure (OR 0·23; P < 0·001), with a greater likelihood of being alive (OR 3·28; P = 0·001) and disease-free (OR 4·33, P < 0·001) at 5 years. CONCLUSION: A pCR following neoadjuvant CRT is associated with excellent long-term survival, with low rates of local recurrence and distant failure.
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Quimiorradioterapia/métodos , Neoplasias Retais/terapia , Adenocarcinoma/terapia , Antimetabólitos Antineoplásicos/uso terapêutico , Intervalo Livre de Doença , Feminino , Fluoruracila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Resultado do TratamentoRESUMO
BACKGROUND: For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer. METHODS: A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011. RESULTS: Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7. CONCLUSION: Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.
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Canal Anal/cirurgia , Complicações Pós-Operatórias/etiologia , Neoplasias Retais/cirurgia , Idoso , Feminino , Humanos , Masculino , Recidiva Local de Neoplasia/mortalidade , Tratamentos com Preservação do Órgão/métodos , Neoplasias Retais/mortalidade , Resultado do TratamentoRESUMO
This article focuses on recent trends and outcomes of bariatric surgery. The outcomes discussed include perioperative morbidity and mortality, weight loss, long-term complications and the impact of bariatric surgery on comorbidities, cardiovascular risk and mortality.
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Cirurgia Bariátrica , Obesidade Mórbida/cirurgia , Hemorragia Pós-Operatória , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/mortalidade , Cirurgia Bariátrica/tendências , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Humanos , Obesidade Mórbida/complicações , Hemorragia Pós-Operatória/mortalidade , Fatores de Risco , Resultado do Tratamento , Estados Unidos/epidemiologia , Redução de PesoRESUMO
BACKGROUND: Historically breast cancer surgery was associated with significant psychosocial morbidity and suboptimal cosmetic outcome. Recent emphasis on women's quality of life following breast cancer treatment has drawn attention to the importance of aesthetic outcome and potential benefits of immediate breast reconstruction (IBR). Our primary aim was to assess patient's quality of life after IBR, compared to a matched group undergoing breast conservation. We also investigated the oncological safety and morbidity associated with immediate reconstruction. METHODS: A prospectively collected database of all breast cancer patients who underwent IBR at a tertiary referral breast unit was reviewed. Patients were reviewed clinically, and administered two validated quality of life questionnaires, at least one year after completing their treatment. RESULTS: 255 patients underwent IBR following mastectomy over a 55 month period. Reconstruction with ipsilateral latissimus dorsi flap was most commonly performed (88%). After mean follow-up of 36 months, IBR patients' quality of life was comparable to a group of age-matched women (n = 160) who underwent breast conserving surgery (p = 0.89). No patient experienced local recurrence (0%), distant metastases developed in 4.8% and disease related mortality was 2.2%. Post-operative morbidities included wound infection (11.8%), chronic pain (2.0%), capsular contracture (11%; 36% of whom had radiotherapy) and fat necrosis (14.1%). No patient experienced flap loss. CONCLUSIONS: IBR is a highly acceptable form of treatment for women requiring mastectomy. With high rates of patient satisfaction, low associated morbidity, and proven oncological safety, it is an appropriate recommendation for all women requiring mastectomy.
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Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Qualidade de Vida , Transplante de Pele/métodos , Adulto , Idoso , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
Bariatric surgery is well established as a safe and effective treatment for morbid obesity and related metabolic diseases. As an elective procedure, it is critical that individuals considering bariatric surgery should be carefully selected, extensively evaluated, and optimized in order to achieve optimal outcomes. This patient population has unique and challenging issues, including an extensive range of potential medical, psychiatric, and psychological comorbidities, and often patients have unrealistic expectations of the surgery. Therefore, a multidisciplinary, comprehensive and timely assessment preoperatively is of great importance. Individual bariatric units utilise different preoperative patient evaluation protocols. There is at present no uniformly accepted or recommended practice. In this article we describe what we believe are the essential components of a preoperative bariatric surgery evaluation, with supporting evidence for each recommendation. We also present a protocol currently in practice at a high volume bariatric center of excellence; the Bariatric and Metabolic Institute in the Cleveland Clinic, Ohio.
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Cirurgia Bariátrica , Protocolos Clínicos , Obesidade Mórbida/cirurgia , Cuidados Pré-Operatórios , HumanosRESUMO
Obesity and the metabolic syndrome are major public health concerns, and present a formidable therapeutic challenge. Many patients remain recalcitrant to conventional lifestyle changes and medical therapies. Bariatric surgery has made laudable progress in the treatment of obesity and its related metabolic disorders, yet carries inherent risks. Unravelling the molecular mechanisms of metabolic disorders is essential in order to develop novel, valid therapeutic strategies. Mi(cro)RNAs play important regulatory roles in a variety of biological processes including adipocyte differentiation, metabolic integration, insulin resistance and appetite regulation. Investigation of these molecules and their genetic targets may potentially identify new pathways involved in complex metabolic disease processes, improving our understanding of metabolic disorders and influence future approaches to the treatment of obesity. This review discusses the role of miRNAs in obesity and related components of the metabolic syndrome, and highlights the potential of using miRNAs as novel biomarkers and therapeutic targets for these diseases.
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Síndrome Metabólica/genética , MicroRNAs/fisiologia , Obesidade/genética , Adipócitos/citologia , Animais , Regulação do Apetite/genética , Biomarcadores , Glicemia/metabolismo , Diferenciação Celular , Diabetes Mellitus/genética , Expressão Gênica , Homeostase/genética , Humanos , Resistência à Insulina/genética , MicroRNAs/genéticaRESUMO
Breast cancer is a complex phenotypically diverse genetic disease, involving a variety of changes in gene expression and structure. Recent advances in molecular profiling technology have made great progress in unravelling the molecular taxonomy of breast cancer, which has shed new light on the aetiology of the disease and also heralded great potential for the development of novel biomarkers and therapeutic targets. Mi(cro)RNAs are a contemporary class of small noncoding endogenous RNA molecules, generating great excitement in the clinical and scientific communities. The recent discovery that miRNA expression is frequently dysregulated in cancer has uncovered an entirely new repertoire of molecular factors upstream of gene expression, which warrants extensive investigation to further elucidate their precise role in malignancy. We present a comprehensive and timely review of the role of miRNAs in cancer: addressing miRNA function, their putative role as oncogenes or tumor suppressors, with a particular emphasis on breast cancer throughout. We discuss the recent discovery of quantifiable circulating cancer-associated miRNAs, which heralds immense potential for their use as novel minimally invasive biomarkers for breast and other cancers. Finally, we comment on the potential role of miRNAs in breast cancer management, particularly in improving current prognostic tools and achieving the goal of individualized cancer treatment.