Risk factors for post-operative complications after sentinel lymph node biopsy for cutaneous melanoma: Results from a large cohort study.

BACKGROUND: A sentinel lymph node (SLN) biopsy is a common surgical procedure for cutaneous melanoma. Our aim was to evaluate risk factors for early post-operative complications after SLN biopsy and to examine the impact of complications on health care resource utilisation. METHODS: We performed a retrospective cohort study including all adult patients who underwent a SLN biopsy for cutaneous melanoma in the Stockholm region from 2006 to 2014. Data of patient and tumour characteristics were collected from medical records, as well as information on complications and outpatient visits within 30 days from surgery. Risk factors were evaluated through logistic regression. RESULTS: Out of 886 patients who underwent SLN biopsy during the study period, 109 (12.3%) had one or several post-operative complications. The most common complication was a wound infection (7.7%), followed by seroma (6.4%). The risk of a post-operative complication was increased in patients with diabetes (odds ratio (OR) = 10.0, 95% confidence interval (CI) 4.0-24.6), who had inguinal location of SLN (OR = 2.7, 95% CI 1.7-4.3), who were male (OR = 1.9, 95% CI 1.2-2.9) and who had ulceration of the primary tumour (OR = 1.6, 95% CI 1.0-2.6). Individuals with post-operative complications had more visits to the outpatient clinic (p < 0.05). CONCLUSION: Complications after SLN biopsy affect 12.3% of patients. Our results suggest that patients with diabetes, who had inguinal SLN biopsy and who were male have increased risk, and this might warrant more intense post-operative surveillance.

Near Infrared Spectroscopy as a Predictor for Shunt Requirement During Carotid Endarterectomy.

OBJECTIVE/BACKGROUND: Near infrared spectroscopy (NIRS) continuously monitors regional cerebral oxygenation (rSO2) in the frontal lobes. This method may be used in patients during carotid endarterectomy to indicate the need for shunting. The aim of the study was to evaluate the value of NIRS in determining the need for selective shunting during CEA. A secondary aim was to compare NIRS with stump pressure. METHODS: Between January 2013 and October 2016, 185 patients from two vascular units, undergoing CEA under local anaesthesia were prospectively included. All patients gave informed consent to participate; there were no exclusion criteria. A Foresight® oximeter was used for rSO2 measurement, which was compared with stump pressure. Receiver operating characteristic curve analysis was used to identify optimal cutoff points, and sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Twenty patients (10.8%) developed neurological symptoms during clamping. Mean stump pressure was lower in the group that developed neurological symptoms than in the group who did not (34 ± 19 mmHg vs. 55 ± 17 mmHg [p < . 01]). Corresponding NIRS results for the decrease in rSO2 on the ipsilateral side was 15 ± 7% versus 4 ± 6% (p < .01). Using stump pressure ≤50 mmHg as cutoff value for predicting symptoms, the sensitivity was 85% (95% confidence interval [CI] 64-95) and specificity 54% (95% CI 46-61). With a relative decrease in NIRS saturation (ΔrSO2) of 9%, sensitivity was 95% (95% CI 76-99), and specificity 81% (95% CI 74-86) to predict ischaemic symptoms during carotid clamping. Neurological deterioration during carotid clamping was detected in one patient with a relative decrease in rSO2 of <9% compared with three patients with a stump pressure >50 mmHg. CONCLUSION: NIRS allows continuous non-invasive monitoring of cerebral oxygenation during CEA, with high sensitivity and acceptable specificity in predicting cerebral ischaemia and the need for shunting, which makes it an attractive alternative to stump pressure.

Safety of Intra-arterial Catheter Directed Thrombolysis: Does Level of Care Matter?

OBJECTIVES: The aim was to assess whether the level of care influenced the safety related outcomes of catheter directed thrombolysis (CDT) for patients presenting with limb ischaemia and dialysis access thrombosis. METHODS: This was a retrospective cohort study. All consecutive patients at two tertiary referral centres for vascular surgery undergoing CDT for limb ischaemia and dialysis access thrombosis (N = 252) between 2012 and 2014 were included. Patients at Centre 1 were cared for on a general vascular ward and patients at Centre 2 were kept on a post-operative recovery unit with an increased level of care including invasive haemodynamic monitoring. Patient medical records were retrospectively scrutinised and data collected on comorbidities, anti-thrombotic medication, indications for CDT, technical success of CDT, bleeding and non-bleeding related complications, and transfer to a higher level of care. RESULTS: There were no differences in the frequency of non-bleeding related complications between Centre 1 and Centre 2. Patients on the vascular ward had a higher frequency of minor bleeding (p = .002) but there was no difference in major bleeding (p = .12). Eleven patients on the ward required an increased level of care for medical reasons and six were moved for a lack of resources. The presence of cardiac disease was an independent risk factor for patient transfer (OR 3.2; 95% CI 1.04-9.8, p = .04). CONCLUSIONS: CDT may be undertaken outside of a high dependency setting without a significantly increased risk of complications. Pre-existing cardiac disease was an independent risk factor for transfer to a higher level of care. These findings could have an implication for the clinical cost-effectiveness of CDT.

Peri-procedural Risk with Urgent Carotid Artery Stenting: A Population based Swedvasc Study.

OBJECTIVES: Current European Society for Vascular Surgery guidelines recommend that patients with a symptomatic carotid stenosis should be operated on within 14 days of onset of symptoms. Recent reports indicate that carotid endarterectomy (CEA) within 2 days of a neurological event may be associated with a higher peri-procedural risk of stroke. Whether urgent carotid artery stenting (CAS) carries a similar high risk is unclear. The aim of this study was to analyze if urgent CAS increases the peri-procedural risks. METHODS: Retrospective analysis of all CAS registered in Swedvasc, a validated nationwide registry, between January 1, 2005, and March 20, 2014. Only symptomatic patients treated for a stenosis of the internal carotid artery were included. Patients were categorized according to time from index event to surgery; 0-2 days, 3-7 days, 8-14 days, and 15-180 days. Primary outcome was 30 day combined stroke and death rate. RESULTS: 323 patients underwent CAS for symptomatic carotid artery stenosis. The demographic and clinical data were similar in the groups. No procedure related complications or deaths were observed in the urgent CAS group. The 30 day combined stroke and death rate did not differ significantly between the groups; zero of 13 (0%; 95% CI 0-26.6) in the group treated 0-2 days versus four of 85 (4.7%; 95% CI 1.5-11.9), at 3-7 days, five of 80 (6.3%; 95% CI 2.4-14.1) at 8-14 days, and six of 145 (4.1%; 95% CI 1.7-8.9) for the patients treated at 15-180 days (p = .757). Stroke and death were not more frequent for patients treated within 1 week compared with after 1 week: 4 out of 98 (4.1%; 95% CI 1.3-9.0) versus 11/225 (4.9%; 95% CI 2.7-8.6) (p = .751). CONCLUSIONS: In this national registry study, CAS performed within 1 week of the onset of a neurologic event was not associated with an additional risk of a peri-operative complication compared with those treated subsequently.

Outcome after 7 years of carotid artery stenting and endarterectomy in Sweden - single centre and national results.

OBJECTIVES: The aim was internal vascular centre quality-control measures to compare single-centre results with the national perspective, as well as analysing the Swedish results from carotid artery stenting (CAS) and comparing a relatively high-volume single centre with the Swedish Vascular Registry (Swedvasc) data. The second aim was to compare CAS and carotid artery endarterectomy (CEA) outcomes for the same 7-year period. DESIGN: Retrospective review of a single high-volume centre (Södersjukhuset (SÖS)) (approximately 30 CAS year(-1) approximately 90 CEA year(-1)) versus Swedvasc National data. MATERIALS AND METHODS: All consecutive selective patients treated with CAS at SÖS for a stenosis of the internal carotid artery (n = 208) or CEA (n = 552) between 2004 and 2011 were compared with all patients in Swedvasc registered for CAS (n = 258) and CEA (n = 6474). Primary outcome was 30-day frequency of stroke or death. Secondary outcome was stroke/death/acute myocardial infarction (AMI). RESULTS: The 30-day frequency of any stroke or death after CAS at SÖS compared to the national data was 2.9% and 7.4%, respectively (P = 0.04). The 30-day AMI/stroke/death frequency was 3.4% and 9.5%, respectively (P = 0.01). After CEA during the same time period, the Swedvasc national data had a 4.4% frequency of 30-day stroke and death and 5.8% for AMI/stroke/death. CONCLUSIONS: CAS is not as safe as CEA from a national perspective but our results indicate that a single centre can achieve acceptable results with CAS.

The risk for cutaneous malignant melanoma, melanoma in situ and intraocular malignant melanoma in relation to tobacco use and body mass index.

BACKGROUND: The incidence of cutaneous malignant melanoma (CMM) and melanoma in situ (MIS) has been increasing during the last 50 years. Malignant melanoma (MM) is also the most common intraocular malignancy (IMM). Besides ultraviolet radiation, the cause of these tumours is largely unknown. OBJECTIVES: We designed a study to examine the effect of body mass index (BMI) and tobacco use on the risk for MM and MIS. METHODS: Analyses were performed on a nationwide cohort of 339 802 Swedish construction workers. Exposure information was collected prospectively by questionnaires combined with personal interviews. RESULTS: Follow up yielded a total of 7 663 400 person-years during which 1639 workers developed MM/MIS. The risk for MM/MIS was reduced in current or previous smokers compared with those who had never smoked, both when analysing all smoking tobacco products combined and when analysing cigarette and pipe smokers separately. The risk was further diminished with longer duration of smoking and greater quantity of tobacco smoked. The effect was more evident in CMM/MIS than in IMM. Snuff taking conferred a decreased risk for CMM/MIS, and a BMI over normal weight range conferred an increased risk for CMM. CONCLUSIONS: Tobacco smoking was found to be inversely associated with the risk for CMM and MIS. The mechanism of action is unknown but it has been suggested to be due to the immune suppressive effect that tobacco exerts which would be protective against deleterious immune reactions caused by, for example, the sun. Neither is the mechanism behind the higher risk for CMM due to being overweight known. One hypothesis is that it is an effect of a hormonal imbalance. Further studies are required to elucidate these mechanisms.

Body site of cutaneous malignant melanoma--a study on patients with hereditary and multiple sporadic tumours.

Individuals with an increased risk of developing cutaneous malignant melanoma (CMM) include members of kindreds with hereditary cutaneous malignant melanoma (HCMM) and patients who have already been treated for a CMM. Some of these patients develop multiple primary cutaneous malignant melanomas (MCMMs). Ultraviolet radiation is the main instigator of CMM. There are indications that patients in these high-risk groups react differently to sunlight than patients who develop a single sporadic CMM. The objectives of this study were to analyse tumour site in patients with HCMM and sporadic MCMM. Data on 2517 patients with 2608 CMMs from a population-based regional cancer registry were used. The new computer program EssDoll was used for the analyses of primary tumour sites. This software is able to analyse any chosen body area(s) with reference to the number of tumours arising there. When the site of the first and second tumours in patients with sporadic MCMM were analysed in a skin 'field division', there was a significant concordance with respect to site (P < 0.0001). In patients with MCMM, the second primary tumour was significantly thinner than the first (P = 0.001). Primary tumour sites in patients with HCMM were compared with those in patients with a single sporadic CMM. In HCMM we found significantly fewer tumours in the head and neck area and more on the trunk. These differences remained significant in two different body area models, even when stratified for age (P < 0.05). In conclusion, a site-concordance was noted for sporadic MCMM. This may be the result of a 'field effect'. Our results indicate that intermittent ultraviolet exposure may be of relatively greater importance than chronic exposure in HCMM.

A new computerized methodology to analyse tumour site in relation to phenotypic traits and epidemiological characteristics of cutaneous malignant melanoma.

BACKGROUND: While sunlight is important in the aetiology of cutaneous malignant melanoma (CMM), the relationship between skin areas receiving intermittent or chronic sun exposure and the development of CMM has not been fully explored. There is a requirement for an improved method for more detailed site mapping and for analysis of tumour density in different areas of the skin in relation to the type of sun exposure, phenotypic traits and prognosis of patients with CMM. OBJECTIVES: To describe and demonstrate the use of EssDoll, a new computerized method to map and analyse tumour sites. METHODS: We have used the new software to analyse data on 2517 patients with 2608 primary CMMs. RESULTS: The results obtained were consistent with previous data on the distribution of CMM in men and women. The distribution of CMM on the back was uneven, with the density on the upper back being twice that on the lower back. CONCLUSIONS: The new methodology allows a more accurate mapping and analysis of skin tumour site, including determination of tumour density. This improves the possibility of analysing tumour site in relation to aetiological, phenotypic and prognostic parameters.

A prospective population-based study of cutaneous malignant melanoma of the head and neck.

UNLABELLED: OBJECTIVES/HYPOTHESIS For cutaneous malignant melanoma (CMM) of the head and neck, neither prognostic factors in population-based groups, nor outcome with respect to surgical resection margins is clear. Therefore, we analyzed data in a regional registry to align treatment results for CMM of the head and neck with prognosis and survival times. STUDY DESIGN: Patient material collected prospectively for an 18-year period in a Swedish cancer registry underwent statistical analyses to establish the most reliable prognostic factors and the influence of surgical treatment on the survival of patients with CMM of the head and neck. METHODS: Data originated from the CMM database of the Stockholm-Gotland area of Sweden. Tumor thickness or invasiveness (Breslow or Clark's levels), extent of surgical margin, sex, histogenetic type, anatomic site, and ulceration were compared statistically for 469 patients. RESULTS: Male patients with head and neck CMM had a 68% 10-year survival rate; the 10-year survival rate for female patients was 87%. The corresponding figures for CMM at other sites were 83% and 90%, respectively. Tumor thickness (or Clark level of invasion) was the only statistically significant prognostic factor in a multivariate analysis (P < .001). The surgical resection margin seemed to be of no importance to outcome. CONCLUSIONS: Long-term survival after treatment for CMM of the head and neck is better than reported in most earlier publications, presumably because our evaluation used population-based materials, an important factor in accurate reporting of this kind. Tumor thickness is the main prognostic factor in estimating outcome.

Epidemiological characteristics of cutaneous malignant melanoma of the head and neck--a population-based study.

Since cutaneous malignant melanoma (CMM) and melanoma in situ (MIS) of the head and neck have only partially been differentiated from CMM of other anatomic sites, these lesions are classified in detail in this study. Data from 756 patients derived from the population-based register of the Stockholm-Gotland area were analyzed and the findings showed that the incidence of CMM was 3.4 times higher in the face compared to the skin outside the head-neck area and that lentigo maligna melanoma was 74 times and nodular melanoma 2.3 times more common in the face. Mean age at diagnosis was significantly higher for patients with CMM of the head and neck irrespective of histogenetic type. Tumor site within the head and neck related to age at diagnosis. CMM of the head and neck differs from CMM of other locations. Epidemiological data are in agreement with the hypothesis that UV radiation (chronic or intermittent) may give rise to melanomas with various phenotypic traits.

Results of rectocele repair. A prospective study.

PURPOSE: This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation. METHODS: Twenty-five patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology. RESULTS: Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction. CONCLUSIONS: Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.