RESUMO
BACKGROUND: This study aims to examine the relationship between weather changes (atmospheric pressure and temperature) and incidence of rupture of abdominal aortic aneurysm (AAA). METHODS: All patients with ruptured infrarenal AAA and who were referred to our institution between August 1998 and August 2015 were prospectively entered into a database of which a retrospective review of a ruptured AAA was performed. The needed information about the daily atmospheric pressure and air temperature could be extracted from the meteorological unit in Cologne. RESULTS: During the study period (6,225 days), a total number of 154 patients with confirmed ruptured AAA were identified. Basic patients' characteristics are tabulated. The mean daily atmospheric pressure during the study was 1,004.04 ± 8.79 mBar ranging from 965.40-1031.80 mBar. The mean atmospheric pressure on the days of rupture was 1,004.03 vs. 1,004.68 on those days when no rupture occurred (P = 0.34). The mean atmospheric pressure on the day of rupture and that on the preceding day was not significantly different (1,004.78 vs. 1,005.44 with P = 0.13). The air temperature (10.62 ± 6.25 vs. 10.77 ± 6.83°C, P = 0.787) was equally distributed between days of rupture events and control days. CONCLUSIONS: The present study could not show a significant association between the monthly and seasonal difference in atmospheric pressure and the prevalence of AAA rupture as it has been supposed by previous studies.
Assuntos
Aneurisma da Aorta Abdominal/epidemiologia , Ruptura Aórtica/epidemiologia , Pressão Atmosférica , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Bases de Dados Factuais , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Estações do Ano , Temperatura , Fatores de TempoRESUMO
BACKGROUND: To present a model of decision and cost-effectiveness analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy (CEA) and the rate of preventable future events and the impact of real-world adherence of best medical treatment (BMT) on cost-effectiveness of both therapeutic options. METHODS: We used data from the current literature to define values for a base case and perform a sensitivity analysis. The primary end point was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either prophylactic CEA or adherent and nonadherent best medical treatment, respectively. RESULTS: The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is 44 days over the course of 5 years in case of nonadherent best medical treatment. Over a 5-year time horizon, prophylactic CEA would be cost-effective in 50.8% of bootstrap replicates and nonpersistent BMT might be economically dominant in 11.1%. The probability that CEA would be cost-effective at a willingness-to-pay (WTP) threshold of Euro 50,000/quality-adjusted life year gained was 71.8%. In 17.9% prophylactic CEA would be more costly and effective than persistent BMT, but its incremental cost-effectiveness ratio was greater than the WTP, so persistent BMT would be optimal. CONCLUSIONS: In this model, in case of real-world drug adherence, it was likely that a strategy of early endarterectomy might be a cost-effective or even the dominant therapeutic option in comparison with a strategy of medical therapy alone (deferred surgery). If background any-territory stroke rates on contemporary medical therapy would fall substantially below 0.7%, surgery would cease to be cost-effective.
Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/economia , Fidelidade a Diretrizes , Idoso , Benchmarking , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/mortalidade , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de SaúdeRESUMO
A persistent sciatic artery is a very rare vascular anomaly with an estimated incidence of 0.025-0.06% and with less than 200 described cases in the literature. During early embryonic development, the sciatic artery delivers the major blood supply to the lower limb and usually disappears when the superficial femoral artery has developed properly. The usual form of presentation in adults is the aneurysmal degeneration of the sciatic artery or less frequently with another complication (thrombosis, embolism, neuralgia). We describe three cases of a complete sciatic artery (two cases are bilateral and one is unilateral) associated with lower limb ischemia caused by embolism from the aneurysmal degeneration of the sciatic artery at the buttock level in two cases and atherosclerotic degeneration of the lower limb arteries in the third case. We also describe two combined therapy methods consisted of limb revascularization with vein-graft bypass and endovascular embolization of the aneurysm with vascular plug in the first case, in the second case combination of localized thrombolysis therapy followed by a bypass and an ilio-pedal vein bypass in the third one. And we discuss later the reported clinical outcome after surgical and endovascular treatment of this anomaly in the literature.
Assuntos
Aneurisma/terapia , Artérias/cirurgia , Aterosclerose/terapia , Embolia/terapia , Embolização Terapêutica , Procedimentos Endovasculares , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Terapia Trombolítica , Malformações Vasculares/complicações , Veias/transplante , Idoso , Aneurisma/complicações , Aneurisma/diagnóstico por imagem , Aneurisma/cirurgia , Angiografia Digital , Índice Tornozelo-Braço , Artérias/anormalidades , Artérias/diagnóstico por imagem , Aterosclerose/complicações , Aterosclerose/diagnóstico por imagem , Aterosclerose/cirurgia , Angiografia por Tomografia Computadorizada , Embolia/diagnóstico por imagem , Embolia/etiologia , Embolia/cirurgia , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Isquemia/cirurgia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Malformações Vasculares/diagnóstico por imagemRESUMO
BACKGROUND: Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated. METHODS: A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I(2) statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5% risk of type I error, being the standard in most meta- analyses and systematic reviews. RESULTS: 58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95% CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I(2) = 36%), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95% CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95% CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95% CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men. CONCLUSIONS: Meta-analyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.
Assuntos
Estenose das Carótidas/mortalidade , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Complicações Pós-Operatórias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Fatores Etários , Estenose das Carótidas/complicações , Comorbidade , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Análise de Regressão , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Resultado do TratamentoRESUMO
BACKGROUND: Although widely applied, the cost-effectiveness of endovenous laser ablation (EVLT) for varicose veins has not been established. METHODS: Cost-effectiveness analysis was performed on the evaluation of EVLT for the treatment of uncomplicated varicose veins by using published data from randomizd clinical trials regarding the costs and the quality of life. Incremental cost per quality-adjusted life year (QALY) gained at 6 months following treatment was calculated. Sensitivity analysis was carried out to investigate the uncertainty associated with the results of our analysis. RESULTS: Over the time horizon of 1-6 months, it was found that the incremental cost of EVLT compared with conventional surgery was 466.66 and the incremental effect was -0.007 QALY at 1 month, -0.0075 QALY at 3 months and 0.0 QALY at 6 months. This shows that the strategy "EVLT" was dominated by the strategy "HL/S" at any time point for the base cases analyses. The results of various alternative economic evaluations indicated that EVLT may be a potentially cost effective (i.e. incremental cost effectiveness ratio of between 12158.67 and 514721.67 per QALY, respectively) treatment option compared to conventional surgical treatment for varicose veins with a certainty between 54.9 and 98.8 %. CONCLUSION: For patients with uncomplicated varicose veins and evidence of saphenofemoral reflux, surgical treatment for varicose veins offers a robust health benefit for relatively less costs compared to EVLT.
Assuntos
Análise Custo-Benefício , Terapia a Laser/economia , Veia Safena/cirurgia , Varizes/cirurgia , Técnicas de Apoio para a Decisão , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: In recent years, the relative benefits of endovascular repair (EVAR) in the treatment of ruptured abdominal aortic aneurysms (rAAAs) compared with those of open repair have been postulated. However, sufficient quantification and evidence-based validation of the role of EVAR in the care pathway for these patients is still lacking. The aim of the present meta-analysis was to investigate the impact of hemodynamic instability and other potential risk factors on 30-day mortality of EVAR versus open repair for rAAAs by performing a meta-regression analysis of previously published data. METHODS: Studies comparing perioperative outcomes of endovascular and open repair of ruptured infrarenal or juxtarenal abdominal aortic aneurysm were considered for analysis. All types of comparative studies, including prospective or retrospective, observational studies, or randomized controlled trials (RCTs), were included. Meta-analysis was undertaken using the Mantel-Haenszel method, with a standard continuity correction of 0.5. A random-effects model was used owing to the variability in baseline characteristics in each article. Furthermore, an odds ratio (OR) for 30-day mortality adjusted for patients' hemodynamic condition at presentation in the hospital was calculated by performing a meta-regression analysis. RESULTS: The entire meta-analysis population comprised 81,681 patients (63 studies), of whom 13,706 underwent EVAR and the remaining 67,975 had an open repair of their rAAA. Without correction for hemodynamic instability, patients undergoing EVAR had a significantly lower 30-day mortality rate than patients having open repair (OR, 0.512; 95% confidence interval [CI], 0.457-0.574; P < 0.01). Moderate heterogeneity among the studies was identified (I(2) = 53.303%), and the likelihood of publication bias was low (P = 0.183). In the RCTs alone (3 studies), patients undergoing EVAR had no significantly lower 30-day mortality rate than patients with open repair (OR, 0.930; 95% CI, 0.691-1.253; P < 0.633). In all studies available, after adjustment for patients' hemodynamic condition at presentation to the hospital, the OR for 30-day mortality was 0.872 (95% CI, 0.598-1.270; P = 0.474), as well, indicating no significant difference between the 2 therapeutic options. CONCLUSIONS: Because a hemodynamically unstable condition may result in poorer clinical outcome, we calculated the 30-day mortality OR adjusted for patients' hemodynamic condition. After adjustment, there was no benefit in 30-day mortality for EVAR compared with that in open surgery.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Ruptura Aórtica/diagnóstico , Ruptura Aórtica/mortalidade , Ruptura Aórtica/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Hemodinâmica , Humanos , Razão de Chances , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: This study weighed the cost and benefit of thoracic endovascular aortic repair (TEVAR) vs open repair (OR) in the treatment of an acute complicated type B aortic dissection by (TBAD) estimating the cost-effectiveness to determine an optimal treatment strategy based on the best currently available evidence. METHODS: A cost-utility analysis from the perspective of the health system payer was performed using a decision analytic model. Within this model, the 1-year survival, quality-adjusted life-years (QALYs), and costs for a hypothetical cohort of patients with an acute complicated TBAD managed with TEVAR or OR were evaluated. Clinical effectiveness data, cost data, and transitional probabilities of different health states were derived from previously published high-quality studies or meta-analyses. Probabilistic sensitivity analyses were performed on uncertain model parameters. RESULTS: The base-case analysis showed, in terms of QALYs, that OR appeared to be more expensive (incremental cost of 17,252.60) and less effective (-0.19 QALYs) compared with TEVAR; hence, in terms of the incremental cost-effectiveness ratio, OR was dominated by TEVAR. As a result, the incremental cost-effectiveness ratio (ie, the cost per life-year saved) was not calculated. The average cost-effectiveness ratio of TEVAR and OR per QALY gained was 56,316.79 and 108,421.91, respectively. In probabilistic sensitivity analyses, TEVAR was economically dominant in 100% of cases. The probability that TEVAR was economically attractive at a willingness-to-pay threshold of 50,000/QALY gained was 100%. CONCLUSIONS: The present results suggest that TEVAR yielded more QALYs and was associated with lower 1-year costs compared with OR in patients with an acute complicated TBAD. As a result, from the cost-effectiveness point of view, TEVAR is the dominant therapy over OR for this disease under the predefined conditions.
Assuntos
Aneurisma Aórtico/economia , Aneurisma Aórtico/cirurgia , Dissecção Aórtica/economia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/economia , Procedimentos Endovasculares/economia , Custos Hospitalares , Doença Aguda , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/mortalidade , Aneurisma Aórtico/complicações , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Humanos , Modelos Econômicos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Tempo , Resultado do TratamentoRESUMO
In carotid surgery, it could be useful to know which patient will tolerate carotid cross-clamping in order to minimize the risks of perioperative strokes. In this clinical study, an artificial neuronal network (ANN) was applied and compared with conventional statistical methods to assess the value of various parameters to predict shunt necessity. Eight hundred and fifty patients undergoing carotid endarterectomy for a high-grade internal carotid artery stenosis under local anesthesia were analyzed regarding shunt necessity using a standard feed-forward, backpropagation ANN (NeuroSolutions); NeuroDimensions, Gainesville, FL) with three layers (one input layer, one hidden layer, one output layer). Among the input neurons, preoperative clinical (n = 9) and intraoperative hemodynamic (n = 3) parameters were examined separately. The accuracy of prediction was compared to the results of a regression analysis using the same variables. In 173 patients (20%) a shunt was used because hemispheric deficits or unconsciousness occurred during cross-clamping. With the ANN, not needing a shunt was predicted by preoperative and intraoperative parameters with an accuracy of 96% and 91%, respectively, where the regression analysis showed an accuracy of 98% and 96%, respectively. Those patients who needed a shunt were identified by preoperative parameters in 9% and by intraoperative parameters in 56% when the ANN was used. Regression analysis predicted shunt use correctly in 10% using preoperative parameters and 41% using intraoperative parameters. Intraoperative hemodynamic parameters are more suitable than preoperative parameters to indicate shunt necessity where the application of an ANN provides slightly better results compared to regression analysis. However, the overall accuracy is too low to renounce perioperative neuromonitoring methods like local anesthesia.
Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Monitorização Intraoperatória , Redes Neurais de Computação , Seleção de Pacientes , Acidente Vascular Cerebral/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Constrição , Feminino , Hemodinâmica , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Valor Preditivo dos Testes , Curva ROC , Radiografia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Fatores de TempoRESUMO
The detection of single tumor cells or tumor cell clusters represents an important issue in intraoperative frozen section analysis. For example, surgical margins may be evaluated in order to minimize the number of additional operations. Furthermore, intraoperative diagnosis of lymph node micrometastasis (LNM) may help to define the area of appropriate lymph node dissection. In addition to haematoxylin and eosin (H&E)-stained sections, immunohistochemical detection of single tumor cells or cell clusters may be helpful in this context. The aim of this study was to evaluate the clinical significance, reliability and sensitivity of intraoperative rapid immunostaining of frozen sections. Therefore, we compared the results of rapid immunohistochemical staining of frozen sections and paraffin sections applying the EnVision and Histofine(R) detection systems. In a prospective immunohistochemical study, paraffin and frozen sections of 20 gastric cancer specimens were analyzed. Paraffin as well as frozen sections were stained immunohistochemically applying the EnVision and Histofine detection systems. As primary antibodies, AE1/AE3 (anti-cytokeratin), EMA (anti-MUC1) and B lymphocyte marker anti-CD20 were applied. The rapid immunostaining procedure was able to be completed within 10-13 min. Rapid immunohistochemical staining of frozen and paraffin sections of the same tumors resulted in comparable immunoreactivity. The rapid EnVision and Histofine procedures allowed immunostaining of frozen sections in less than 13 min. These methods can represent useful additional tools in routine surgical pathology and research, enabling a more accurate frozen section diagnosis compared to staining with H&E alone. Intraoperative rapid immunostaining can be a simple and useful technique to detect LNM.
Assuntos
Adenocarcinoma/patologia , Neoplasias Gástricas/patologia , Idoso , Anticorpos/química , Antígenos CD20/imunologia , Antígenos de Neoplasias/imunologia , Feminino , Secções Congeladas , Humanos , Imuno-Histoquímica/métodos , Masculino , Mucina-1 , Mucinas/imunologia , Inclusão em ParafinaRESUMO
Splenic rupture after colonoscopy is rare. Only 44 cases previously have been reported in the English literature. Partial capsular avulsion is the proposed mechanism of injury. Any condition causing increased splenocolic adhesions may be a predisposing factor to splenic injury. One case of splenic injury after colonoscopy is reported in addition to a complete review of the literature.
Assuntos
Colonoscopia/efeitos adversos , Ruptura Esplênica/etiologia , Idoso , Feminino , Humanos , Esplenectomia , Ruptura Esplênica/diagnóstico por imagem , Ruptura Esplênica/cirurgia , Tomografia Computadorizada por Raios XRESUMO
INTRODUCTION: To compare carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in the treatment of carotid stenosis, including two recently published, prospective, randomized trials of these therapies. EVIDENCE ACQUISITION: A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed. Primary outcomes were death, stroke, and myocardial infarction. EVIDENCE SYNTHESIS: Carotid artery stenting as compared with CEA was associated with a 61% increase in the risk of periprocedural death or stroke (Peto OR, 1.609; 95% confidence interval [CI]: 1.193-2.170; P=0.002). The trial sequential monitoring boundary was crossed by the cumulative Z-curve, suggesting firm evidence for at least a 20% relative risk increase of periprocedural death or stroke and any stroke compared with CEA. Carotid artery stenting as compared with CEA was associated with a 42% increase in the risk for the composite of periprocedural stroke or death plus ipsilateral stroke thereafter (Peto OR, 1.417; 95% CI: 1.074-1.870; P=0.0014). CONCLUSIONS: In this largest and most comprehensive meta-analysis to date using outcomes that are standard in contemporary studies, CAS was associated with an increased risk of both periprocedural and intermediate- to long-term outcomes.
Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/terapia , Stents , Idoso , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The primary study objective was to develop a microsimulation model to predict preventable first-ever and recurrent strokes and mortality for a population of medically or surgically managed octogenarians with substantial (>60%) asymptomatic carotid artery stenosis and comparing an adherent with a real-world nonadherent best medical treatment (BMT) regimen subjected to sex. METHODS: A Monte Carlo microsimulation model was constructed with a 14-year time horizon and with 10,000 patients. Probabilities and values for clinical outcomes were obtained from the current literature. RESULTS: The stratification of the microsimulation estimates by treatment strategy within the female group of octogenarians showed a statistically significant lower stroke rate during follow-up for carotid endarterectomy (CEA) compared with nonadherent BMT (P < 0.0001) as well as compared with adherent BMT (P < 0.0001). In male octogenarians, the CEA strategy was also associated with statistically significant lower stroke rates compared with adherent and nonadherent BMT (P < 0.0001 and P < 0.0001, respectively). For each treatment strategy, female octogenarians had a statistically significant longer overall long-term survival compared with male octogenarians (P < 0.0001, respectively). In terms of stratification by sex, in octogenarian men and women, long-term survival was significantly better for adherent BMT compared with nonadherent BMT, and CEA was associated with a significant better long-term survival compared with nonadherent BMT. CONCLUSIONS: In the present microsimulation, in real-world drug adherence, it was likely that a strategy of early endarterectomy was beneficial in octogenarians with significant asymptomatic carotid artery disease compared with BMT alone.
Assuntos
Estenose das Carótidas/mortalidade , Estenose das Carótidas/terapia , Endarterectomia das Carótidas/mortalidade , Adesão à Medicação/estatística & dados numéricos , Modelos de Riscos Proporcionais , Medição de Risco/métodos , Acidente Vascular Cerebral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas/mortalidade , Terapia Combinada/mortalidade , Terapia Combinada/estatística & dados numéricos , Simulação por Computador , Feminino , Fibrinolíticos/uso terapêutico , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Prognóstico , Reprodutibilidade dos TestesRESUMO
Staging of gastric carcinoma depends on exact lymph node status. However, very small lymph nodes can easily be missed during routine examination as they are obscured by the surrounding adipose tissue. The purpose of the present study was to verify the usefulness of a lymph node revealing solution (LNRS) in gastric cancer and compare its accuracy concerning the detection of lymph node metastases to immunostaining with cytokeratin antibodies. A total of 11 consecutive patients underwent standardized D2 gastrectomy for primary gastric adenocarcinoma. Non-fixed, the entire surgical specimen was searched for lymph nodes by palpation and visualization. The remaining tissue was immersed for 24 h in LNRS. The lymph nodes stood out as white chalky nodules on the background of yellow fat. All identified lymph nodes were resected and analyzed histologically. In 5 patients with pN0 status, immunostaining of the lymph nodes was performed using cytokeratin-specific antibodies. The conventional preparation of lymph nodes from the unfixed tissue yielded a total of 452 lymph nodes (mean 41.1 lymph nodes/patient; range, 26 to 56), and 201 of them had a pN0 status. After fixation using LNRS, 138 additional nodes could be detected (mean 12.5 lymph nodes/patient; range, 3 to 21), and 70 of them with a pN0 status. The detection rate of extremely small lymph nodes (<3 mm) increased by 27% compared to the conventional preparation technique (p=0.0017). After application of the LNRS lymph node analysis, it was not necessary to change the UICC node (N) stage in any cases. Additionally, we performed immunostaining in 5 specimens with pN0 status. In one patient, 10 micrometastases/disseminated tumour cells were detected. Thus, after immunohistochemical re-evaluation, one patient had to be upstaged pN(i+). By performing standardized LAD systematically and detailed lymph node preparation by the pathologist, a routine application of the LNRS method in gastric carcinoma is not recommended. Immunohistochemical techniques aid in identifying micrometastatic disease in lymph nodes missed in routine H&E staining in order to define the pN(i) status according to the TNM classification.
Assuntos
Ácido Acético , Adenocarcinoma/patologia , Etanol , Éter , Formaldeído , Estadiamento de Neoplasias , Neoplasias Gástricas/patologia , Humanos , Imuno-Histoquímica/métodos , Queratinas/imunologia , Metástase Linfática/diagnóstico , Reprodutibilidade dos TestesRESUMO
HYPOTHESIS: The management of simultaneously occurring intra-abdominal abnormalities and abdominal aortic aneurysms or aortoiliac occlusive disease is controversial. The aim of this retrospective study was to analyze whether gastrointestinal operations performed at the same time as aortic repair increase the postoperative morbidity and mortality rate. METHOD: Between January 1, 1989, and December 31, 1997, a total of 42 patients underwent open aortic tube (n = 33) or bifurcated grafting (n = 9) and simultaneous surgery of 1 or more gastrointestinal abnormalities. In a matched-pairs analysis for each of the aforementioned patients, a control patient with an exclusive aortic procedure was selected. For each matched pair the following aspects were noted: the type of operative procedure, time of execution, duration of the surgical procedure, the duration of postoperative ventilatory assistance, intensive care unit and hospital stays, the number of blood units transfused, the use of antibiotics, and the main postoperative complications. RESULTS: The comparison between the matched pairs revealed no statistically significant difference for postoperative morbidity or mortality rate or length of intensive care unit and hospital stays. There were no operative or hospital deaths. None of the patients has (median follow-up, 68 months) shown evidence of graft infection. CONCLUSION: A 1-stage operation management is feasible if appropriate care is given to the technical details and if the rules of antisepsis are followed.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Arteriopatias Oclusivas/cirurgia , Gastroenteropatias/cirurgia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/mortalidade , Implante de Prótese Vascular , Distribuição de Qui-Quadrado , Procedimentos Cirúrgicos do Sistema Digestório , Feminino , Gastroenteropatias/complicações , Gastroenteropatias/mortalidade , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
According to international guidelines, stable patients with uncomplicated Type B aortic dissection (TBAD) should receive optimal medical treatment. Despite adequate antihypertensive therapy, the long-term prognosis of these patients is characterized by a significant aortic aneurysm formation in 25-30% within four years, and survival rates from 50 to 80% at five years and 30 to 60% at 10 years. In a prospective randomized trial, preemptive thoracic endovascular aortic repair (TEVAR) in patients with chronic uncomplicated TBAD was associated with an excess early mortality (due to periprocedural hazards), but the procedure showed its benefit in prevention of aortic-specific mortality at five years of follow-up. However, preemptive TEVAR may not be the treatment of choice in all patients with uncomplicated TBAD because of the inherent periprocedural complications like stroke, paraparesis, and death, as well as stent graft-induced complications (i.e., retrograde dissection or endoleaks). Thus, the TEVAR-related deaths and complications (especially paraplegia and stroke) raise concerns that moderate the better survival with TEVAR at five years. By timely identification of those patients prone for developing complications, early intervention, preferably in the subacute or early chronic phase, may improve the overall long-term outcome for these patients. Therefore, early detectable and reliable prognostic factors for adverse events are essential to stratify patients who can be treated medically and those who will benefit from rigorous follow-up and, in the long-term, from timely, or even prophylactic, TEVAR. Several studies have identified prognostic factors in TBAD such as aortic diameter, partial false lumen thrombosis, false lumen thickness, and location of the primary entry tear. Combining these clinical and radiological predictors may be essential to implement a patient-specific approach designed to intervene only in those patients who are at high risk of developing complications to improve the long-term outcomes of patients with uncomplicated Type B aortic dissection.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Técnicas de Apoio para a Decisão , Mortalidade Hospitalar , Redes Neurais de Computação , Procedimentos Cirúrgicos Vasculares/mortalidade , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Bases de Dados Factuais , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
The hypothesis driving this study was that photodynamic therapy (PDT) may limit abdominal aortic aneurysm growth due to matrix changes. The aortas of 12 rats were incubated with elastase using a newly modified experimental aneurysm model (3.5 mg/ml). Rats were allocated to an elastase-only group (n = 6) to study the elastase-induced aneurysm growth and an elastase ± PDT group to evaluate if PDT limited aneurysm growth (n = 6). PDT was performed with the photosensitizer methylene blue, and thermoneutral laser light (660 nm) was applied (120 J/cm(2), 100 mW/cm(2)) using a diode laser. Four untreated rats served as controls. The arteries were analysed after 4 weeks based on histology, immunohistochemistry and morphometry. This modified rat elastase model led to reproducible aneurysm development with no elastase-induced mortality compared with control animals (circumference, controls: 2.9 ± 0.2 vs. elastase: 5.5 ± 0.9 mm; P < 0.01). PDT after elastase incubation did not inhibit inflammatory cell infiltration. No significant change in the circumference was observed between elastase incubation and PDT treatment after elastase incubation (circumference, elastase: 5.5 ± 0.9 vs. elastase and PDT: 6.1 ± 0.8 mm; P < 0.01). Despite a PDT-induced resistance to protease digestion, PDT did not reduce aortic dilatation in the elastase-treated rat aorta. These findings suggest that PDT may not be a useful modality to prevent aneurysm growth.
Assuntos
Aneurisma da Aorta Abdominal/tratamento farmacológico , Azul de Metileno/farmacologia , Fotoquimioterapia , Fármacos Fotossensibilizantes/farmacologia , Animais , Aneurisma da Aorta Abdominal/induzido quimicamente , Aneurisma da Aorta Abdominal/imunologia , Aneurisma da Aorta Abdominal/patologia , Modelos Animais de Doenças , Imuno-Histoquímica , Masculino , Elastase Pancreática , Ratos , Ratos Sprague-Dawley , Fatores de TempoRESUMO
Wegener granulomatosis (WG) is a systemic disease of unknown etiology characterized by necrotizing granulomatous inflammation, tissue necrosis, and variable degrees of vasculitis, typically in small and medium-sized blood vessels. The classic clinical pattern is a triad involving the upper airways, lungs, and kidneys. However, large vessel aneurysm is an extremely rare finding in WG. We describe a 67-year-old Caucasian male with formerly proven WG who presented with a progressively growing superficial femoral artery aneurysm. Histologic findings revealed necrotizing granulomatous vasculitis involving this artery.
Assuntos
Aneurisma/etiologia , Artéria Femoral , Granulomatose com Poliangiite/complicações , Idoso , Aneurisma/diagnóstico por imagem , Aneurisma/cirurgia , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/cirurgia , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Absorbable sutures are not well accepted for reconstruction in high-pressure arterial segments because the suture line might break and aneurysmal changes could develop. This hypothesis was checked in the clinical setting of carotid surgery. METHODS: The morphology of the carotid artery was evaluated by color-coded ultrasound in four groups of patients: group A, 25 patients who underwent standard carotid endarterectomy and patchplasty, including a transverse plication for which absorbable sutures had been used; group B, 10 patients who underwent eversion endarterectomy and reinsertion using absorbable sutures; group C, 15 patients who underwent standard carotid endarterectomy and patchplasty without a transverse placation; group D, 20 patients who suffered from atherosclerotic disease but did not have previous carotid surgery or other carotid pathology. All operations had been performed at least 3 years earlier than the actual examination. RESULTS: Along the internal carotid artery, where an aneurysmal change would have been expected to occur, no differences in absolute size or calculated elliptical cross-sectional vessel area were found. Patients after eversion endarterectomy did not show signs of aneurysmal changes in the area of reinsertion at the carotid bifurcation. CONCLUSIONS: Even in the long-term, for this group of patients, no significant aneurysmal changes of arterial reconstructions in carotid surgery performed with absorbable sutures were observed.
Assuntos
Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/métodos , Suturas , Implantes Absorvíveis , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Resultado do Tratamento , Ultrassonografia Doppler em CoresRESUMO
PURPOSE: To compare radiofrequency obliteration (RFO) and conventional surgery with respect to postoperative complications, effectiveness of treatment, and quality of life (QoL). METHODS: Several healthcare databases were interrogated to identify all studies published between 1994 and 2007 comparing RFO in primary varicosis to conventional therapy with vein ligation and stripping. Of 65 articles identified, 8 studies representing 428 patients [224 (52%) endovenous RFO and 204 (48%) stripping] were eligible for the meta-analysis. Adverse events, effectiveness, and QoL outcomes were assessed at several time points up to 2 years. RESULTS: There were significant reductions in tenderness and ecchymosis at 1 week and significantly fewer hematomas at 72 hours, 1 week, and 3 weeks associated with RFO. There was no significant difference between the RFO and surgery in immediate or complete great saphenous vein (GSV) occlusion, incomplete GSV closure, freedom from reflux, recurrent varicose veins, recanalization, or neovascularization. QoL results significantly favoring RFO over surgery included return to normal activity and return to work. CONCLUSION: It seems that RFO benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion, and reflux may alter with longer follow-up. The lack of such data demonstrates the need for further randomized clinical trials of RFO versus conventional surgery.