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2.
World J Surg ; 46(8): 1886-1895, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35430647

RESUMO

BACKGROUND: Acute acalculous cholecystitis (AAC) is often diagnosed in critically ill patients. Percutaneous cholecystostomy tube (PCT) placement facilitates less invasive gallbladder decompression in patients who are poor surgical candidates. Specific guidelines for optimal management of AAC patients following PCT placement remain to be defined. We hypothesize that AAC patients are at lower risk of recurrent cholecystitis than acute calculous cholecystitis (ACC) patients and do not require cholecystectomy after PCT placement. METHODS: A retrospective review of patients who underwent PCT placement for AAC or ACC between 6/1/2007 and 5/31/2019 was performed. Primary outcome was recurrent cholecystitis and interval cholecystectomy for patients surviving 30 days after PCT placement. Secondary outcome was 30 day mortality. A cox regression model calculated the adjusted hazard ratio (AHR) for the outcomes. RESULTS: Eighty-four AAC and 85 ACC patients underwent PCT placement. Compared to ACC patients, more AAC patients were male (72.6 vs. 48.2%; p < 0.01), younger (median age 62 vs. 73 years; p < 0.01), and required intensive care (69.0 vs. 52.9%; p = 0.04), with lower median Charlson Comorbidity Index (4.0 vs. 6.0; p < 0.01). 30 day mortality was higher among AAC patients than ACC patients (45.2 vs. 21.2%; p < 0.01). 2/24 (8.3%) AAC patients and 5/31 (16.1%) ACC patients developed recurrent cholecystitis at a median 208.0 days (IQR:64.0-417.0) after PCT placement and 115.0 days (IQR:7.0-403.0) following PCT removal. Cox regression analysis demonstrated that AAC patients had lower likelihood of interval cholecystectomy compared to ACC patients (AHR 2.35; 95% CI:1.11,4.96). CONCLUSION: Recurrent cholecystitis is rare in patients surviving 30 days following PCT placement. When compared with ACC patients, fewer AAC patients require cholecystectomy.


Assuntos
Colecistite Aguda , Colecistite , Colecistostomia , Colecistectomia , Colecistite/cirurgia , Colecistite Aguda/complicações , Colecistite Aguda/cirurgia , Colecistostomia/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
3.
Surgery ; 171(2): 399-404, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34706825

RESUMO

BACKGROUND: We examined the link between increased intra-abdominal pressure, intracranial pressure, and vasopressin release as a potential mechanism. Intra-abdominal pressure, produced by abdominal-cavity insufflation with carbon dioxide (CO2) during laparoscopic abdominal procedures to facilitate visualization, is associated with various complications, including arterial hypertension and oliguria. METHODS: Mean arterial pressure, optic nerve sheath diameter, measured as a proxy for intracranial pressure, plasma vasopressin, serum and urine osmolarity, and urine output were measured 4 times during laparoscopic sleeve gastrectomy in 42 patients: before insufflation with CO2 (T0); after insufflation to 15 cm water (H2O) pressure, with 5 cm H2O positive end-expiratory pressure (T1); after positive end-expiratory pressure was raised to 10 cm H2O (T2); and after a return to the baseline state (T3). Mean values at T0 to T3 and the directional consistency of changes (increase/decrease/ unchanged) were compared among the 4 data-collection points. RESULTS: Statistically significant elevations (all P ≤ .001) were noted from T0 to T1 and from T0 to T2 in mean arterial pressure, optic nerve sheath diameter, and vasopressin, followed by decreases at T3. For optic nerve sheath diameter and vasopressin, the increases at T1 and T2 occurred in 98% and 100% of patients, ultimately exceeding normal levels in 88 and 97%, respectively. Conversely, urine output fell from T0 to T1 and T2 by 60.9 and 73.4%, decreasing in 88.1% of patients (all P < .001). Patients with class II obesity exhibited statistically greater increases in optic nerve sheath diameter and vasopressin, but statistically less impact on urine output, than patients with class III obesity. CONCLUSION: Increased mean arterial pressure, intracranial pressure, and vasopressin release appear to be intermediary steps between increased intra-abdominal pressure and oliguria. Further research is necessary to determine any causative links between these physiological changes.


Assuntos
Hipertensão Intra-Abdominal/fisiopatologia , Hipertensão Intracraniana/fisiopatologia , Oligúria/fisiopatologia , Pneumoperitônio Artificial/efeitos adversos , Vasopressinas/metabolismo , Adulto , Idoso , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/métodos , Humanos , Hipertensão Intra-Abdominal/epidemiologia , Hipertensão Intra-Abdominal/etiologia , Hipertensão Intracraniana/epidemiologia , Hipertensão Intracraniana/etiologia , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Oligúria/epidemiologia , Oligúria/etiologia , Estudos Prospectivos , Sistema Vasomotor/fisiopatologia , Adulto Jovem
4.
J Surg Res ; 270: 405-412, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34749121

RESUMO

BACKGROUND: Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. METHODS: Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. RESULTS: Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. CONCLUSIONS: Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.


Assuntos
Colecistite Aguda , Colecistostomia , Colecistite Aguda/diagnóstico , Colecistite Aguda/cirurgia , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento
5.
J Surg Res ; 267: 651-659, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34273795

RESUMO

INTRODUCTION: Surgery is the initial treatment of choice for patients with resectable adrenocortical carcinoma (ACC). We sought to determine factors associated with non-operative management of resectable ACC. METHODS: 2004-2016 National Cancer Database (NCDB) was queried to identify patients with AJCC/ENSAT Stage I-III ACC. Patients who underwent surgery (S) were compared to those who did not undergo surgery (NS). Multivariate logistic regression was used to identify factors associated with NS. Kaplan-Meier estimates used to assess survival. RESULTS: Two thousand-seventy patients with Stage I-III ACC were identified, of which 17.5% were NS. 85.9% of NS patients were not offered surgery; 69.9% of NS patients did not receive chemotherapy or radiation therapy. NS were older and less likely to receive care at an Academic center or high volume center (≥5 cases during the study period). NS patients were more likely to have advanced T stage and N1 disease. On multivariate regression, factors associated with lower odds of surgery include older age (OR 1.03, 95% CI 1.02-1.06), T4 disease (OR 3.34, 95% CI 1.05-10.68), and treatment at a community center (OR 2.92, 95% CI 1.58-5.40). Overall median survival was significantly poorer for NS patients (50.4 versus 78.4 months, P < 0.01). CONCLUSION: Patients with locally advanced ACC are less likely to undergo an operation, while those treated at centers with more operative experience or Academic facilities are more likely to undergo an operation. As the surgery-first approach is the current standard of care for resectable ACC, these patients may be best served at high volume Academic facilities.


Assuntos
Neoplasias do Córtex Suprarrenal , Carcinoma Adrenocortical , Neoplasias do Córtex Suprarrenal/cirurgia , Carcinoma Adrenocortical/cirurgia , Humanos , Estimativa de Kaplan-Meier , Estadiamento de Neoplasias , Estudos Retrospectivos , Resultado do Tratamento
7.
Surg Endosc ; 29(4): 992-4, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25115864

RESUMO

Superior mesenteric artery (SMA) syndrome is a rare condition in which the duodenum is compressed between the SMA and aorta. This often occurs following extreme weight loss and has been reported in the bariatric population. We present the first reported case of SMA syndrome following sleeve gastrectomy. The patient underwent laparoscopic duodenojejunostomy and recovered uneventfully. The following is a review of the literature and detailed operative approach in the attached video.


Assuntos
Gastrectomia/efeitos adversos , Laparoscopia/efeitos adversos , Obesidade/cirurgia , Complicações Pós-Operatórias , Síndrome da Artéria Mesentérica Superior/etiologia , Adulto , Feminino , Gastrectomia/métodos , Humanos , Síndrome da Artéria Mesentérica Superior/diagnóstico , Tomografia Computadorizada por Raios X
8.
J Gastrointest Surg ; 18(10): 1737-43, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25118640

RESUMO

INTRODUCTION: The laparoscopic adjustable gastric band (LAGB) can be revised to sleeve gastrectomy (LSG) for various reasons. Data are limited on the safety and efficacy of single-stage removal of LAGB and creation of LSG. METHODS: A retrospective review of cases was performed from 2010 to 2013. From the primary LSG group, a control group was matched in a 2:1 ratio. RESULTS: Thirty-two patients underwent single-stage revision from LAGB to LSG, with a control group of 64. The most common indication for revision was insufficient weight loss (62.5%). Operative time for revision and control groups was 134 and 92 min, respectively (p < 0.0001). Hospital stay was 3.22 and 2.59 days, respectively (p = 0.02). Overall, the 30-day complication rate for revision and control patients was 14.71 and 6.25%, respectively (p = 0.20). There were no leaks, one stricture (3.13%) in the revision group, and one reoperation for bleeding in the control group (1.56%). For patients with BMI >30 at surgery, change in BMI at 12 months for revision and control was 8.77 and 11.58, respectively (p = 0.02). CONCLUSION: Single-stage revision can be performed safely, with minimal increases in hospital stay and 30-day complications. Weight loss is greater in those who undergo primary LSG compared to those who undergo LSG as revision.


Assuntos
Gastrectomia/métodos , Gastroplastia/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/epidemiologia , Redução de Peso/fisiologia , Adulto , California/epidemiologia , Feminino , Seguimentos , Gastrectomia/efeitos adversos , Gastroplastia/efeitos adversos , Humanos , Incidência , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Falha de Tratamento
9.
Am Surg ; 79(10): 997-1000, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24160786

RESUMO

Breast cancer is now the leading cause of death in Hispanic women (HW). Internet, e-mail, and instant text messaging may be cost-effective in educating HW about breast health and in reducing breast cancer mortality. We surveyed 905 HW women attending a free health fair about their technology use, acculturation, insurance status, mammography use, and breast cancer knowledge. Data were analyzed by t test or χ(2) tests. Mean age was 51.9 ± 14.2 years (range, 18 to 88 years). Ninety-two per cent were foreign-born. Most had completed some high school (39%) or elementary (38%) education. Most (62%) were uninsured. The majority spoke (67%) and read (66%) only Spanish. Only 60 per cent of HW older than 40 years had a recent mammogram. HW older than 40 years who had not had a recent mammogram were younger (mean 54.9 ± 10.8 vs 58 ± 10.4 years) and less likely to have health insurance (25 vs 44%; P < 0.001). Most HW never use the Internet (58%) or e-mail (64%). However, 70 per cent have mobile phones (66% older than 40 years), and 65 per cent use text messaging daily (58% older than 40 years, P = 0.001). In fact, 45 per cent wish to receive a mammogram reminder by text. Text messaging may be an inexpensive way to promote breast health and screening mammography use among uninsured HW.


Assuntos
Neoplasias da Mama/prevenção & controle , Correio Eletrônico , Promoção da Saúde/métodos , Hispânico ou Latino , Internet , Mamografia , Envio de Mensagens de Texto , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/etnologia , Correio Eletrônico/estatística & dados numéricos , Emigrantes e Imigrantes , Feminino , Pesquisas sobre Atenção à Saúde , Exposições Educativas , Conhecimentos, Atitudes e Prática em Saúde/etnologia , Hispânico ou Latino/etnologia , Humanos , Internet/estatística & dados numéricos , Los Angeles , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Envio de Mensagens de Texto/estatística & dados numéricos , Adulto Jovem
10.
Am Surg ; 79(10): 1009-12, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24160789

RESUMO

Paget's disease of the nipple is often found in conjunction with underlying ductal carcinoma in situ (DCIS). In isolation, Paget's disease of the nipple, like DCIS, confers an excellent prognosis for survival. Our objective was to determine if Paget's disease identified with synchronous parenchymal DCIS has as favorable an outcome as Paget's disease alone. We analyzed a prospectively maintained pathology database and medical records to identify all patients diagnosed with Paget's disease of the nipple between June 1996 and December 2011. Overall survival was analyzed using Kaplan-Maier statistics and Cox proportional hazards modeling. Seventy-four patients were identified with Paget's disease: five (6%) with isolated Paget's of the nipple, 22 (30%) associated with parenchymal DCIS, and 47 (64%) associated with invasive cancer (± DCIS). Unexpectedly, patients with Paget's disease and DCIS had a worse prognosis than those with Paget's disease alone. Survival correlated with pathologic stage at diagnosis. Among the 16 deaths, median survival was 2.8 years (range, 0.1 to 15.2 years). Median follow-up for the entire cohort was 4.2 years (range, 0.1 to 15.2 years). Thus, Paget's disease with parenchymal DCIS may confer worse survival than isolated Paget's disease of the nipple, suggesting the difficulty of identifying invasive carcinoma within a background of DCIS.


Assuntos
Neoplasias da Mama/mortalidade , Carcinoma Intraductal não Infiltrante/mortalidade , Neoplasias Primárias Múltiplas/mortalidade , Mamilos , Doença de Paget Mamária/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/diagnóstico , Carcinoma Intraductal não Infiltrante/cirurgia , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Mastectomia , Pessoa de Meia-Idade , Neoplasias Primárias Múltiplas/diagnóstico , Neoplasias Primárias Múltiplas/cirurgia , Doença de Paget Mamária/diagnóstico , Doença de Paget Mamária/cirurgia , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida
12.
Am Surg ; 78(10): 1122-7, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23025955

RESUMO

Chest wall irradiation decreases locoregional recurrence and breast cancer-related mortality in women at high risk for recurrence after mastectomy. Many women undergoing mastectomy desire immediate breast reconstruction. Postmastectomy radiation therapy (PMRT), however, increases the risk of surgical complications and may adversely affect the reconstructed breast. We compared outcomes of immediate latissimus dorsi myocutaneous flap (Lat Flap) versus tissue expander/implant (EI) reconstruction after mastectomy followed by PMRT in 29 women with invasive breast cancer treated at a single institution between 2009 and 2011. Although patients undergoing EI reconstruction were slightly younger and more frequently underwent bilateral mastectomy, there were no major differences between the groups with respect to patient or tumor characteristics. With a median follow-up of 11 months (Lat Flap) and 13 months (EI) after completion of PMRT, there was a trend toward more wound complications requiring reoperation, including expander/implant loss (n=3), in the EI group. Capsular contracture was the most common sequela of PMRT in the Lat Flap group (67%) but this was easily treated with capsulotomy at the time of nipple-areola reconstruction. Immediate breast reconstruction with a latissimus dorsi myocutaneous flap is a viable option for women undergoing mastectomy who are likely to require chest wall irradiation.


Assuntos
Implantes de Mama , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Mastectomia , Retalhos Cirúrgicos , Expansão de Tecido , Adulto , Idoso , Terapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos
13.
Am Surg ; 77(10): 1361-3, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22127089

RESUMO

Preoperative breast MRI does not decrease re-excision rates in patients who undergo lumpectomy. We evaluated concordance of tumor size on MRI and pathologic size in patients who underwent re-excision of margins after lumpectomy. A retrospective review of patients at the Cedars-Sinai Breast Center who received breast MRI was performed. We found that MRI was performed before lumpectomy in 136 patients. Mean age was 55.2 years (standard deviation ± 12.6). Re-excision occurred in 34 per cent (n = 46). Of those undergoing re-excision, 35 per cent (16/46) were re-excised for ductal carcinoma in situ (DCIS) at the lumpectomy margin. There was no significant difference between radiologic and pathologic size of the tumor (1.94 vs 2.12 cm; P = 0.159). In those who underwent re-excision, the radiologic size was underestimated compared with the pathologic size (2.01 vs 2.66 cm; P = 0.032). Patients with pure DCIS lesions (n = 9) also had smaller radiologic tumor size compared with pathologic (0.64 vs 2.88 cm; P = 0.039), and this difference trended toward significance in those who underwent re-excision (0.55 vs 3.50 cm; P = 0.059). Discordance between tumor size on MRI and pathologic size may contribute to re-excisions in patients who undergo lumpectomy. The limitations of breast MRI to evaluate the extent of DCIS surrounding many breast cancers, and the impact on re-excision rates, should be further evaluated.


Assuntos
Biópsia por Agulha/métodos , Neoplasias da Mama/patologia , Imageamento por Ressonância Magnética/métodos , Mastectomia Segmentar/métodos , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias/métodos , Reoperação/tendências , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/patologia , Carcinoma Ductal de Mama/cirurgia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/cirurgia , Neoplasia Residual/patologia , Neoplasia Residual/cirurgia , Estudos Retrospectivos , Fatores de Tempo
14.
Am Surg ; 77(2): 180-4, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21337876

RESUMO

Little is known about the use of breast MRI as a diagnostic or surveillance tool in patients after bilateral mastectomy. The objective of this study was to evaluate breast MRI after bilateral mastectomy. Participants consisted of 48 women with prior bilateral mastectomy who underwent breast MRI between 2003 and 2009. Seventy-nine breast MRIs were obtained. The median time between mastectomy and first MRI was 36 months. MRI was ordered most often by a medical oncologist (71%). Median age at bilateral mastectomy was 49 years (range, 33 to 72 years). Reasons for obtaining MRI included surveillance in 60 (76%), mass in eight (10%), lymph nodes in four (5%), pain in three (4%), and abscess in one (1%). Overall, 68 (86%) MRIs showed benign imaging findings only. Within the surveillance group, six patients had MRIs with findings that changed management; four patients had some residual breast tissue, and two patients had findings outside the breast that were better evaluated by CT or bone scan and were ultimately benign. MRI confirmed locoregional recurrence in two patients with highly suspicious physical findings. Overall, postmastectomy breast MRI had limited use, finding no unsuspected recurrences within our study group. Although MRI can be helpful to establish the presence of residual breast tissue after bilateral mastectomy, subsequent routine screening breast MRI should be questioned if no residual breast tissue is identified.


Assuntos
Imageamento por Ressonância Magnética/estatística & dados numéricos , Mastectomia , Recidiva Local de Neoplasia/diagnóstico por imagem , Adulto , Idoso , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mamoplastia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Cuidados Pós-Operatórios , Radiografia , Estudos Retrospectivos
15.
Ann Thorac Surg ; 90(5): 1630-6, 2010 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-20971278

RESUMO

BACKGROUND: Gastroesophageal reflux and aspiration contribute to the development of bronchiolitis obliterans and accelerate graft deterioration after lung transplantation (LTx). We evaluated LTx candidates for esophageal motor abnormalities and gastroesophageal reflux. METHODS: Consecutive patients evaluated for LTx underwent 24-hour pH monitoring using a dual-channel pH probe and high-resolution esophageal manometry. High-resolution manometry was also performed in healthy control subjects. The prevalence of abnormal acid exposure was noted in the LTx candidates. RESULTS: Thirty LTx candidates and 10 control subjects were evaluated. Lung transplantation candidates had higher residual upper and lower esophageal sphincter pressures. The mean proportion of peristaltic swallows was 21% lower in LTx candidates. Both hypotensive and aperistaltic swallows were sixfold more prevalent in LTx candidates than in control subjects. All control subjects had normal high-resolution manometry whereas 23 LTx candidates (76.7%) had esophageal peristaltic dysfunction. Abnormal acid exposure time was seen in the proximal and distal esophagus in 25% and 36% of LTx candidates, respectively. Lung transplantation candidates with idiopathic pulmonary fibrosis had more aperistaltic contractions, more negative minimum intrathoracic pressure, and a higher frequency of abnormal distal esophagus acid exposure. The majority of patients with complications after LTx demonstrated motor, anatomic, or pH abnormalities. CONCLUSIONS: Disordered esophageal motor function and gastroesophageal reflux are common in LTx candidates. We believe high-resolution esophageal manometry is a valid tool to use and the abnormalities we identified may be representative of this unique patient population. The role of this study in predicting a worse outcome should be further studied in patients after LTx.


Assuntos
Transtornos da Motilidade Esofágica/epidemiologia , Refluxo Gastroesofágico/epidemiologia , Transplante de Pulmão/efeitos adversos , Adulto , Idoso , Estudos de Casos e Controles , Esfíncter Esofágico Inferior/fisiopatologia , Esfíncter Esofágico Superior/fisiopatologia , Feminino , Humanos , Concentração de Íons de Hidrogênio , Masculino , Manometria , Pessoa de Meia-Idade
16.
Am Surg ; 75(10): 937-40, 2009 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-19886139

RESUMO

The use of MRI in preoperative staging of breast cancer has escalated recently. Breast MRI has greater sensitivity than mammography, ultrasound, and clinical examination in cancer detection. Because of its variable specificity, however, there has been concern that increased MRI use will result in increased rates of mastectomy for early-stage breast cancer. We postulated that mastectomy rates are not affected by trends in MRI use. We performed a retrospective analysis of imaging tests ordered by surgeons at our breast center from 2003 to 2007. We also reviewed all breast cancer cases reported to the National Cancer Database from our institution during the same time period and categorized them as having been treated with mastectomy or breast-conserving surgery. From 2003 to 2007, the number of breast MRIs ordered annually by surgeons increased from 68 to 358. The rate of MRI use increased from 4.1 per every 100 patients seen to 5.7 and from 1.6 per every 100 new patients seen to 2.9. The percentage of women undergoing mastectomy for breast cancer remained unchanged during this 5-year interval. Therefore, although MRI use in breast cancer staging and surveillance has increased, mastectomy rates have not.


Assuntos
Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Mastectomia/estatística & dados numéricos , Estadiamento de Neoplasias , Vigilância da População , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Estudos Retrospectivos
17.
J Gastrointest Surg ; 12(4): 624-8, 2008 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-18176853

RESUMO

BACKGROUND: Several techniques of laparoscopic bile duct exploration and intraoperative endoscopic sphincterotomy (ES) have been developed to treat patients with common bile duct (CBD) stones in one session and avoid the complications of ES. With all these options available, very few randomized controlled trials (RCTs) have been undertaken. This review analyzes those studies. METHODS: We searched PubMed. Four RCTs and a Cochran Database Systematic Review were found. RESULTS: Two RCTs compared preoperative ES and laparoscopic CBD exploration (E) for known CBD stones. Laparoscopic CBDE had shorter length of hospitalization. Two RCTs compared immediate and delayed treatment and found that length of stay was less with laparoscopic CBDE, but clearance rates and morbidity/mortality were similar. CONCLUSIONS: Studies suggest that CBD stones discovered at the time of cholecystectomy are best treated during the same operation. The transcystic approach is safest if applicable. Individual surgeons must be aware of their own capabilities and those of the available endoscopists and perform the safest technique.


Assuntos
Colecistectomia , Cálculos Biliares/diagnóstico , Cálculos Biliares/cirurgia , Laparoscopia , Esfinterotomia Endoscópica , Humanos , Tempo de Internação , Ensaios Clínicos Controlados Aleatórios como Assunto
18.
Obes Surg ; 17(11): 1503-9, 2007 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18219779

RESUMO

BACKGROUND: Gastric electrical stimulation (GES), using the implantable TANTALUS System, is being explored as a treatment for obesity. The system delivers nonstimulatory electrical signals synchronized with gastric slow waves, resulting in stronger contractions. We hypothesized that this GES may enhance gastric emptying and as a result affect plasma ghrelin and insulin homeostasis. The aim was to test the effect of GES on gastric emptying of solids and on ghrelin and insulin blood levels in obese subjects. METHODS: The system consists of 3 pairs of gastric electrodes connected to an implantable pulse generator. Gastric emptying test (GE) of solids was performed twice, on separate days, a few weeks after implantation, before and after initiation of stimulation. Blood samples for ghrelin and insulin were taken at baseline and at 15, 30, 60 and 120 min after the test meal. RESULTS: There were 11 females, 1 male, mean age 39.1 +/- 8.9 years, mean BMI 41.6 +/- 3.4. Data is available from 11 subjects; GE was normal in 9 subjects and accelerated in 2 subjects. GES significantly accelerated GE compared to control: percent retention at 2 hours 18.7 +/- 12.2 vs 31.9 +/- 16.4, respectively (P < 0.01). Overall, there was no significant change in ghrelin or insulin profile after food intake. Ghrelin levels fell significantly at 60 min compared to baseline during stimulation (P = 0.014) and control (P = 0.046). CONCLUSION: GES results in a significant acceleration of gastric emptying of solids in obese subjects. GES did not have a significant effect on postprandial ghrelin levels when compared to control.


Assuntos
Terapia por Estimulação Elétrica/instrumentação , Esvaziamento Gástrico/fisiologia , Grelina/sangue , Obesidade Mórbida/sangue , Obesidade Mórbida/fisiopatologia , Adulto , Índice de Massa Corporal , Eletrodos Implantados , Desenho de Equipamento , Feminino , Humanos , Insulina/sangue , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/terapia , Período Pós-Prandial/fisiologia
19.
Arch Surg ; 141(8): 783-8; discussion 788-9, 2006 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-16924086

RESUMO

HYPOTHESIS: Fludeoxyglucose F 18 (FDG) positron emission tomography (PET) can be used to predict axillary node metastases. DESIGN: Case series. SETTING: Comprehensive breast care center. PATIENTS: Fifty-one women with 54 biopsy-proven invasive breast cancers. INTERVENTION: Whole-body FDG-PET performed before axillary surgery and interpreted blindly. MAIN OUTCOME MEASURES: Axillary FDG activity, quantified by standardized uptake value (SUV); axillary metastases, quantified histologically; and tumor characteristics. RESULTS: There was PET activity in 32 axillae (59%). The SUVs ranged from 0.7 to 11.0. Twenty tumors had an SUV of 2.3 or greater, and 34 had an SUV of less than 2.3. There were no significant differences between these 2 groups except in axillary metastasis size (SUV /=2.3): mean age, 53 vs 58 years (P = .90); mean modified Bloom-Richardson score, 7.7 vs 7.6 (P = .20); lymphovascular invasion present, 25% vs 36% (P = .40); mean Ki-67 level, 25% vs 32% (P = .20); mean tumor size, 2.9 vs 3.2 cm (P = .05); and axillary metastasis size, 0.9 vs 1.7 (P = .001). By adopting an SUV threshold of 2.3, FDG-PET had a sensitivity of 60%, a specificity of 100%, and a positive predictive value of 100%. CONCLUSIONS: Patients with an SUV greater than 2.3 had axillary metastases. This finding obviates the need for sentinel lymph node biopsy or needle biopsy to diagnose axillary involvement. Surgeons can proceed to axillary node dissection to assess the number of nodes involved, eliminate axillary disease, or perhaps provide a survival benefit if preoperative FDG-PET has an SUV greater than 2.3.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Carcinoma Ductal de Mama/diagnóstico por imagem , Carcinoma Lobular/diagnóstico por imagem , Fluordesoxiglucose F18 , Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos , Axila , Biópsia por Agulha Fina , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Carcinoma Ductal de Mama/secundário , Carcinoma Ductal de Mama/cirurgia , Carcinoma Lobular/secundário , Carcinoma Lobular/cirurgia , Feminino , Seguimentos , Humanos , Metástase Linfática , Mastectomia , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Prognóstico , Curva ROC , Estudos Retrospectivos
20.
Cancer J ; 11(1): 36-42, 2005.
Artigo em Inglês | MEDLINE | ID: mdl-15831222

RESUMO

UNLABELLED: Since the advent of laparoscopy and its general acceptance for treating benign diseases, indications for malignant disease have been investigated. Recently, greater evidence shows that laparoscopy for malignant disease is oncologically safe. DESIGN: We review a minimally invasive approach to splenic malignancy and the common malignant diseases involving the spleen. We outline our preferred technique for splenectomy in detail. Additionally, the recent literature is reviewed regarding outcome after laparoscopic splenectomy for benign and malignant disease. The data from three studies, containing a total of 327 were analyzed. Complication rates, mortality, and length of stay were compared. RESULTS: There was no statistically significant difference identified between those undergoing laparoscopic splenectomy for benign versus malignant disease in terms of length of stay, complication rate or mortality. There were significant differences between the two groups in terms of operative time and spleen weight. DISCUSSION: In open splenectomy series for patients with malignant diseases of the spleen, complication and mortality are much higher when compared to those patients undergoing open splenectomy for benign disease. The discussed series show no difference in endpoints when laparoscopy is used. Laparoscopic splenectomy for malignant disease confers significant benefit and rapid recovery for an otherwise at risk population.


Assuntos
Laparoscopia/métodos , Linfoma/cirurgia , Complicações Pós-Operatórias , Esplenectomia/métodos , Neoplasias Esplênicas/cirurgia , Humanos , Resultado do Tratamento
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