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2.
N Engl J Med ; 381(16): 1513-1523, 2019 10 17.
Artigo em Inglês | MEDLINE | ID: mdl-31618539

RESUMO

BACKGROUND: Heartburn that persists despite proton-pump inhibitor (PPI) treatment is a frequent clinical problem with multiple potential causes. Treatments for PPI-refractory heartburn are of unproven efficacy and focus on controlling gastroesophageal reflux with reflux-reducing medication (e.g., baclofen) or antireflux surgery or on dampening visceral hypersensitivity with neuromodulators (e.g., desipramine). METHODS: Patients who were referred to Veterans Affairs (VA) gastroenterology clinics for PPI-refractory heartburn received 20 mg of omeprazole twice daily for 2 weeks, and those with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring. If patients were found to have reflux-related heartburn, we randomly assigned them to receive surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo). The primary outcome was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)-Health Related Quality of Life score (range, 0 to 50, with higher scores indicating worse symptoms) at 1 year. RESULTS: A total of 366 patients (mean age, 48.5 years; 280 men) were enrolled. Prerandomization procedures excluded 288 patients: 42 had relief of their heartburn during the 2-week omeprazole trial, 70 did not complete trial procedures, 54 were excluded for other reasons, 23 had non-GERD esophageal disorders, and 99 had functional heartburn (not due to GERD or other histopathologic, motility, or structural abnormality). The remaining 78 patients underwent randomization. The incidence of treatment success with surgery (18 of 27 patients, 67%) was significantly superior to that with active medical treatment (7 of 25 patients, 28%; P = 0.007) or control medical treatment (3 of 26 patients, 12%; P<0.001). The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% confidence interval, -5 to 38; P = 0.17). CONCLUSIONS: Among patients referred to VA gastroenterology clinics for PPI-refractory heartburn, systematic workup revealed truly PPI-refractory and reflux-related heartburn in a minority of patients. For that highly selected subgroup, surgery was superior to medical treatment. (Funded by the Department of Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT01265550.).


Assuntos
Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/cirurgia , Azia/tratamento farmacológico , Omeprazol/uso terapêutico , Inibidores da Bomba de Prótons/uso terapêutico , Adulto , Baclofeno/uso terapêutico , Desipramina/uso terapêutico , Resistência a Medicamentos , Quimioterapia Combinada , Feminino , Fundoplicatura , Refluxo Gastroesofágico/complicações , Azia/etiologia , Azia/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Relaxantes Musculares Centrais/uso terapêutico , Qualidade de Vida , Inquéritos e Questionários , Veteranos
4.
Aesthet Surg J ; 39(10): 1146-1149, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31335957
5.
J Gastrointest Oncol ; 10(3): 387-390, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31183186

RESUMO

Background: In locally-advanced esophageal cancer (LAEC), providers' concerns regarding eventual surgical candidacy can persuade physicians to defer to definitive doses of 50 Gy or higher preoperatively. We report the successful completion rate of tri-modality therapy (TMT) (documented at the outset) and reasons for TMT non-adherence at a large multi-disciplinary esophageal program. Methods: LAEC patients diagnosed 2007-2016 from a prospective institutional database were subdivided into CRT/S+ [completed chemoradiation (CRT) and surgery] and CRT/S- (CRT and no subsequent surgery) groups. Chart review provided surgery non-adherence reasons. Results: A total of 283 patients met planned TMT criteria: 164 (58.0%) patients received 50 or 50.4 Gy CRT, 27 patients (9.5%) received greater than 50.4 Gy, and 92 patients received less than 50 Gy (32.5%, only 8 patients received CRT to 41.4 Gy); 221 (78.1%) completed surgery (CRT/S+), while 62 (21.9%) failed to advance to surgery (CRT/S-): 25 of 62 CRT/S- patients (40.3%) evidenced metastatic progression before surgery, 4 (6.5%) were deemed unresectable intraoperatively, 4 (6.5%) expired prior to planned surgery (3 from unknown causes, 1 suicide), 8 (12.9%) experienced significant CRT-related medical decompensation and were withdrawn from surgical consideration, 16 (25.8%) voluntarily declined surgery post-CRT (largely due to long-term quality of life concerns), and 5 (8.1%) failed to advance for unknown reasons. Four of the 16 patients who voluntarily declined surgery after CRT received less than 50 Gy. The 22.2% of CRT/S+ patients achieved pathologic complete response (21.6% for adenocarcinoma and 29.0% for squamous cell carcinoma). Conclusions: Our institution's 78% surgery completion rate among TMT-indicated patients highlights the benefits of upfront multidisciplinary care. Metastatic disease development most commonly truncated TMT with a low rate failing due to medical decompensation. Given the number of patients who voluntarily declined surgery following CRT, TMT counseling and involvement of a patient advocate are paramount prior to treatment planning.

6.
Ann Surg Oncol ; 26(2): 514-522, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30377918

RESUMO

BACKGROUND: Early-stage esophageal cancer (stages 0-1) has been shown to have relatively good outcomes after local endoscopic or surgical resection. For this reason, neoadjuvant chemoradiation usually is reserved for higher-stage disease. Some early tumors, however, are found after resection to be more advanced than predicted based on initial clinical staging, termed pathologic upstaging. Such tumors may have benefited from alternate treatment models had their true stage been known preoperatively. This study aimed to identify high-risk features in early esophageal cancers that might predict tumor upstaging and guide more individualized treatment algorithms. METHODS: Through retrospective review of a single-institution foregut disease registry, we evaluated patients who underwent esophagectomy for high-grade dysplasia (Tis) or stage 1 esophageal cancer, searching for factors associated with pathologic upstaging. RESULTS: The review included 110 patients (88% male, median age at diagnosis, 64.5 years) treated between January 2000 and June 2016. Upstaging occurred for 20.9% of the patients, and was more common for patients with angiolymphatic invasion (odds ratio [OR], 11.07; 95% confidence interval [CI], 2.96-41.44; P < 0.001) or signet-ring features (OR, 23.9; 95% CI, 2.6-216.8; P = 0.005). In the absence of other predictors, upstaging was associated with decreased overall survival (P = 0.006). CONCLUSIONS: Approximately 20% of patients with early-stage esophageal cancer may be upstaged at resection. Angiolymphatic invasion and signet-ring features may predict tumors likely to be upstaged, resulting in decreased overall survival.


Assuntos
Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Seleção de Pacientes , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Centros de Atenção Terciária
7.
Ann Surg ; 268(3): 479-487, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30063494

RESUMO

OBJECTIVES: The objectives of this study were to evaluate gender-based differences in faculty salaries before and after implementation of a university-wide objective compensation plan, Faculty First (FF), in alignment with Association of American Medical Colleges regional median salary (AAMC-WRMS). Gender-based differences in promotion and retention were also assessed. SUMMARY BACKGROUND DATA: Previous studies demonstrate that female faculty within surgery are compensated less than male counterparts are and have decreased representation in higher academic ranks and leadership positions. METHODS: At a single institution, surgery faculty salaries and work relative value units (wRVUs) were reviewed from 2009 to 2017, and time to promotion and retention were reviewed from 1998 to 2007. In 2015, FF supplanted specialty-specific compensation plans. Salaries and wRVUs relative to AAMC-WRMS, time to promotion, and retention were compared between genders. RESULTS: Female faculty (N = 24) were compensated significantly less than males were (N = 62) before FF (P = 0.004). Female faculty compensation significantly increased after FF (P < 0.001). After FF, female and male faculty compensation was similar (P = 0.32). Average time to promotion for female (N = 29) and male faculty (N = 82) was similar for promotion to associate professor (P = 0.49) and to full professor (P = 0.37). Promotion was associated with significantly higher retention for both genders (P < 0.001). The median time of departure was similar between female and male faculty (P = 0.73). CONCLUSIONS: A university-wide objective compensation plan increased faculty salaries to the AAMC western region median, allowing correction of gender-based salary inequity. Time to promotion and retention was similar between female and male faculty.


Assuntos
Mobilidade Ocupacional , Docentes de Medicina/economia , Seleção de Pessoal/economia , Médicas/economia , Salários e Benefícios/economia , Cirurgiões/economia , Centros Médicos Acadêmicos/economia , Adulto , Feminino , Humanos , Masculino , Estados Unidos
8.
J Gastrointest Surg ; 22(9): 1501-1507, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29845573

RESUMO

BACKGROUND: Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients. METHODS: We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity. RESULTS: Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p = 0.03). CONCLUSIONS: Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.


Assuntos
Esofagectomia/efeitos adversos , Esôfago/cirurgia , Precondicionamento Isquêmico , Complicações Pós-Operatórias/etiologia , Estômago/irrigação sanguínea , Estômago/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Constrição Patológica/etiologia , Esofagectomia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
9.
World J Surg ; 42(4): 915, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29404752
10.
Am J Surg ; 215(5): 813-817, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29310892

RESUMO

BACKGROUND: Sarcopenia is associated with increased morbidity and mortality in hepatic, pancreatic and colorectal cancer. We examined the effect of sarcopenia on morbidity, mortality, and recurrence after resection for esophageal cancer. METHODS: Retrospective review of consecutive esophagectomies from 2010 to 2015. Computed tomography studies were analyzed for sarcopenia. Morbidity was analyzed using Fischer's test and survival data with Kaplan Meier curves. RESULTS: The sarcopenic group (n = 127) had lower BMI, later stage disease, and higher incidence of neoadjuvant radiation than those without sarcopenia (n = 46). There were no differences in morbidity or mortality between the groups (p = .75 and p = .31, respectively). Mean length of stay was similar (p = .70). Disease free and overall survival were similar (p = .20 and p = .39, respectively). CONCLUSION: There is no association between sarcopenia and increased morbidity, mortality and disease-free survival in patients undergoing esophagectomy for cancer. Sarcopenia in esophageal cancer may not portend worse outcomes that have been reported in other solid tumors.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia , Sarcopenia/epidemiologia , Idoso , Neoplasias Esofágicas/mortalidade , Feminino , Humanos , Masculino , Morbidade , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Prevalência , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida
12.
Am J Surg ; 215(4): 658-662, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29275909

RESUMO

BACKGROUND: Hospital-associated UTI rates in surgery patients have not improved despite recommendations for reducing indwelling catheter days. METHODS: We performed a retrospective review of institutional NSQIP general surgery patient data, 2006-2015. During this time, a UTI-reduction policy was implemented. Demographics, HA-UTI incidence, CA-UTI incidence, indwelling catheter days, straight catheterization rates, and mortality were examined. RESULTS: Females had significantly higher risk of HA-UTI. There was no significant change in HA-UTI (X12 = 0.02, p = .878) or indwelling catheter days (5.18 ±â€¯1.12 days v 3.73 ±â€¯0.39 days, p = .23). Straight catheterizations among those with HA-UTI increased (0.04 ±â€¯0.04 v 0.32 ±â€¯0.12, p = .029). There was no change in CA-UTI (1.38 v 1.11 CAUTI/1000 patient hospital-days P = .555) or in initial indwelling catheter days of patients with CA-UTI (7.2 SD 8.89 v 47.0 SD 7.04 days P = .961) after policy implementation. CONCLUSIONS: The reduction policy increased the number of straight catheterizations for patients developing HA-UTI, but did not reduce the number of initial indwelling catheter days, HA-UTI rates, or CA-UTI rates.


Assuntos
Infecção Hospitalar/prevenção & controle , Cirurgia Geral , Infecções Urinárias/prevenção & controle , Idoso , Cateteres de Demora , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/etiologia , Feminino , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Política Organizacional , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Cateterismo Urinário , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia
13.
Ann Surg ; 267(6): 1000-1006, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29271824

RESUMO

: Dr. Barbara Bartlett Stimson, AB, MD, MedScD, FACS (1898-1986) was a pioneering orthopedic surgeon from a prominent American family who, in 1940, became the first woman certified by the American Board of Surgery (ABS, certificate number 860). It would be another 7 years and approximately 2500 candidates before the next female surgeon would be certified. A member of the third class to admit women to Columbia Medical School and the second female surgical resident to complete training at Columbia-Presbyterian Medical Center, Dr. Stimson was a confident and exceptionally accomplished trailblazer for women in surgery. In this biographical sketch based upon documents from the ABS, and the archives of Vassar College and the College of Physicians and Surgeons at Columbia-Presbyterian Medical Center, Dr. Stimson's motivations, attitudes, and unique accomplishments emerge as testimony to the exceptional career of this driven, self-possessed woman. Stimson was undaunted by the sex-based conventions of her time, and achieved a notable career as a surgeon in the profession she loved; first honing her skills at a busy urban fracture service in New York, then serving with distinction in the Royal Army Medical Corps during World War II, and finally returning to the states to become a respected leader in her field. Her life story and unprecedented ABS certification affirm her conviction that proven skill and ability can be used as a means of overcoming unfounded biases, and helped pave the way for future generations of board certified female surgeons in the United States.


Assuntos
Medicina Militar/história , Ortopedia/história , Médicas/história , Certificação , Feminino , Cirurgia Geral/história , História do Século XX , Humanos , New York , Reino Unido , Estados Unidos
14.
18.
Langenbecks Arch Surg ; 402(8): 1145-1151, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28828685

RESUMO

PURPOSE: Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias. METHODS: A literature review of contemporary and latest studies with highest quality of evidence was completed. This information was examined and compiled in review format. RESULTS: Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac, 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure. Repairs not amenable to key steps may undergo gastropexy and gastrostomy placement as an alternative procedure. CONCLUSIONS: Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have reflux disease, an operative repair is required. A minimally invasive approach is safe and has improved outcomes.


Assuntos
Hérnia Hiatal/diagnóstico , Hérnia Hiatal/cirurgia , Herniorrafia , Hérnia Hiatal/etiologia , Humanos , Laparoscopia
19.
J Laparoendosc Adv Surg Tech A ; 27(9): 915-923, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28486000

RESUMO

INTRODUCTION: Management of benign and malignant esophageal disease has changed rapidly over the past decade. The aim of this study was to analyze evolution in surgical management of esophageal disease at a single academic medical center during this period. MATERIALS AND METHODS: We reviewed a retrospective cohort of patients who underwent esophagectomy between 2004 and 2013. Patient, institutional, treatment, and outcomes variables were reviewed. RESULTS: 317 patients were analyzed. Median age was 63.5 years; 80% were male. Average inhospital mortality rate was 3.8%. Operative indications changed significantly from 2004 to 2013, with more operations performed for invasive malignancy (77% vs. 95%) and fewer for high-grade dysplasia (12% vs. 3%, P = .008). In 2004, Ivor Lewis esophagectomy was the most common surgical technique, but the three-field technique was the operation of choice in 2013. A minimally invasive approach was used in 19% of cases in 2004 and 100% of cases in 2013 (P < .001). Anastomotic leak ranged from 0% to 21% with no significant difference over the study period (P = .18). Median lymph node harvest increased from seven to 18 nodes from 2004 to 2013 (P = .001). Hospital length of stay decreased from 15 to 8 days (P = .001). In 2013, 79% of patients were discharged to home, compared to 73% in 2004 (P = .04). DISCUSSION: Over the last decade, our treatment of esophageal disease has evolved from a predominantly open Ivor Lewis to a minimally invasive three-field approach. Operations for malignancy have also increased dramatically. Postoperative complications and mortality were not significantly changed, but were consistently low during the latter years of the study.


Assuntos
Antineoplásicos/uso terapêutico , Quimiorradioterapia/métodos , Neoplasias Esofágicas/terapia , Esofagectomia/métodos , Adulto , Idoso , Anastomose Cirúrgica/métodos , Fístula Anastomótica/cirurgia , Doenças do Esôfago , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Terapia Neoadjuvante , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos
20.
Am J Surg ; 214(2): 299-302, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28460739

RESUMO

INTRODUCTION: Trends in the utilization of Heller myotomy for achalasia in the U.S. over time have not been previously described. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample (NIS) database, we analyzed patients undergoing Heller myotomy for achalasia over a 20-year period (1992-2011) to estimate rates of Heller myotomy, locations where the procedures were performed (rural, urban or teaching) and changes in technique (laparoscopic vs open) as well as outcomes of length of stay and in-hospital mortality. RESULTS: Over the last 20 years, the total number of Heller myotomies performed in the U.S. has increased (1576 cases in 1992 to 5046 cases in 2011, p = 0.001). These procedures are now being performed laparoscopically (0.9%-67.0%, p < 0.001) and at urban teaching hospitals (45.4%-77.1%, p < 0.001). In-hospital mortality has decreased (0.9%-0.3%, p = 0.006). Hospital length of stay has decreased from 7 days to 2 days (p < 0.001). DISCUSSION: These data show a trend of increasing utilization of laparoscopic Heller myotomy at teaching institutions with decreased in-hospital mortality and shorter LOS.


Assuntos
Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Procedimentos Cirúrgicos do Sistema Digestório/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Estados Unidos
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