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1.
Mol Psychiatry ; 25(2): 283-296, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31745239

RESUMO

Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.

2.
Ann Vasc Surg ; 51: 141-146.e2, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29522875

RESUMO

BACKGROUND: Significant stenoses in arteriovenous fistulae (AVFs) or arteriovenous grafts (AVGs) with limitation of flow and dialysis inadequacy should prompt consideration for fistuloplasty. We sought to identify fistulae, lesions, and patient-specific variables, which predict for outcomes after fistuloplasty. METHODS: Data were extracted retrospectively from a renal access database from 2011 to 2016 of patients undergoing fistuloplasty. Demographics, comorbidities, outcomes of intervention, and flow rates documented on preintervention and postintervention duplex were collected. Secondary analysis of factors associated with postfistuloplasty flow rates of >600 mL/min, previously shown to be predictive of not requiring future intervention, was performed. RESULTS: Of 204 attempted fistuloplasties, 176 were completed. One hundred forty (79.5%) were native AVFs and 34 (19.3%), AVGs (no data for 2). Median stenosis treated was 75%, with a majority (43.8%) in the proximal outflow vein. Flow rate on duplex after fistuloplasty was significantly better in AVFs (mean improvement 189.2 mL/min) than that in AVGs (mean improvement 51.8 mL/min; P = 0.034). Greatest flow improvement occurred for needling site stenotic lesions compared with other locations (from anastomosis to central vein) but was not significant. Brachio-brachial or brachio-axillary AVGs did significantly (P < 0.05) worse than all other fistulae types. The presence of hypertension was predicted for postfistuloplasty flow rate of >600 mL/min. CONCLUSIONS: Flow rates after fistuloplasty vary depending on the type of fistula treated and the presence of hypertension. Knowledge of this can lead to better patient selection and counseling for fistuloplasty.


Assuntos
Derivação Arteriovenosa Cirúrgica , Implante de Prótese Vascular , Diálise Renal , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Velocidade do Fluxo Sanguíneo , Implante de Prótese Vascular/efeitos adversos , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla
3.
J Gastrointest Surg ; 22(2): 194-202, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28770418

RESUMO

BACKGROUND: Historically, patients presenting acutely with paraesophageal hernia and requiring urgent operation demonstrated inferior outcomes compared to patients undergoing elective repair. METHODS: A prospective IRB-approved database was used to retrospectively review 570 consecutive patients undergoing paraesophageal hernia repair between 2000 and 2016. RESULTS: Thirty-eight patients presented acutely (6.7%) and 532 electively. Acute presentation was associated with increased age (74 vs. 69 years) but similar age-adjusted Charlson comorbidity scores. A history of chest pain, intrathoracic stomach ≥75%, and mesoaxial rotation were more common in acute presentations. Emergency surgery was required in three patients (8%), and 35 patients were managed in a staged approach with guided decompression prior to semi-elective surgery. Acute presentation was associated with an increased hospital stay (5 (2-13) days vs. 4 (1-27) days, p = 0.001). There was no difference in postoperative Clavien-Dindo severity scores. One patient in the elective group died, and the overall mortality was 0.2%. CONCLUSION: Our findings suggest that a majority of patients presenting with acute paraesophageal hernia can undergo a staged approach instead of urgent surgery with comparable outcomes to elective operations in high-volume centers. We suggest elective repair for patients presenting with a history of chest pain, intrathoracic stomach ≥75%, and a mesoaxial rotation.


Assuntos
Descompressão Cirúrgica , Hérnia Hiatal/cirurgia , Herniorrafia , Estômago/cirurgia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/etiologia , Dor no Peito/cirurgia , Descompressão Cirúrgica/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Endoscopia Gastrointestinal , Feminino , Hérnia Hiatal/complicações , Herniorrafia/efeitos adversos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Gravidade do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Volvo Gástrico/etiologia , Volvo Gástrico/cirurgia
4.
Ann Thorac Surg ; 103(6): 1700-1709, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28433224

RESUMO

BACKGROUND: Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair. METHODS: From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board-approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (<70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses. RESULTS: Overall, 524 patients underwent surgical PEH repair (<70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients <70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence. CONCLUSIONS: PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.


Assuntos
Hérnia Hiatal/cirurgia , Herniorrafia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Hérnia Hiatal/patologia , Herniorrafia/métodos , Herniorrafia/mortalidade , Humanos , Incidência , Laparoscopia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Fatores de Risco
5.
Ann Surg Oncol ; 23(8): 2673-8, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27020584

RESUMO

BACKGROUND: Invasive esophageal cancers have been managed historically with esophagectomy. Low-risk T1b patients are being proposed for nonsurgical management. The purpose of this study was to evaluate the ability of endoscopic mucosal resections (EMR) to identify low-risk T1b patients and to review surgical treatment outcomes for T1b cancer. METHODS: All esophageal cancer patients, in an institutional review board-approved prospective database, between 2000 and 2013 with clinical stage (cT1bN0), pathological stage (pT1bN0), and no neoadjuvant therapy were retrospectively reviewed. RESULTS: Fifty-one patients, 38 pT1b and 13 cT1b, were assessed. All cT1b had preoperative EMR and five were found to be understaged at esophagectomy. pT1bN0 patients had a mean age of 66 years, mean BMI of 30, and 95 % had adenocarcinoma. Thirty-eight pT1bN0 patients underwent esophagectomy with a median hospital length of stay (LOS) of 9 days. Complications occurred in 14 patients, but 71 % were minor (Accordion score 1-2). In-hospital 30- and 90-day mortality was zero. EMR specimens were re-reviewed to assess low-risk criteria. Degree of differentiation and the presence of lymphovascular invasion could be assessed in all EMR specimens; however, assessment of submucosal invasion limited to the superficial submucosal layer could not be determined in the majority of cases. Kaplan-Meier 5-year overall survival in pT1bN0 patients was 78.7 %. CONCLUSIONS: Clinical staging of superficial esophageal cancer can be inaccurate especially in submucosal tumors. EMR should be routinely used for preoperative staging. Healthy patients with clinical tumor stage greater than cT1a should undergo multidisciplinary review and be considered for surgical resection.


Assuntos
Adenocarcinoma/patologia , Carcinoma de Células Escamosas/patologia , Ressecção Endoscópica de Mucosa/mortalidade , Neoplasias Esofágicas/patologia , Esofagectomia/mortalidade , Adenocarcinoma/cirurgia , Idoso , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida
6.
Surg Endosc ; 30(8): 3391-401, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26541725

RESUMO

BACKGROUND: Previous reports comparing endoscopic therapy (ET) and surgical therapy (ST) have predominantly assessed patients with high-grade dysplasia. The study aim was to compare ET to ST in physiologically fit patients with cT1a adenocarcinoma (EAC). METHODS: Review of two prospective databases yielded 100 patients presenting with clinical cT1a EAC between 2000 and 2013. Only physiologically fit patients who were candidates for either treatment were analyzed. RESULTS: Presenting patient characteristics were similar between ET (n = 36) and ST groups (n = 49). Surgical patients were less likely to be staged with EMR (43 vs 100 %) and were associated with mass lesions >1 cm at EGD (p = 0.01), multifocal EAC (p = 0.03), and positive margins for EAC on EMR (p < 0.05). On multivariate analysis, only multifocal HGD was an independent factor for surgery. Following esophagectomy, R0 resection rates for Barrett's esophagus and cancer were 100 %. Incidence of surgery decreased over the study period from 85 to 25 %. All ET patients had EMR, and 28 patients underwent additional ablative therapies for Barrett's esophagus. Following ET, eradication rates of EAC, dysplasia, and BE were 92, 81, and 53 %, respectively. Morbidity rates were comparable between groups (ST 51 % vs ET 39 %, p = 0.31). In-hospital mortality rate was zero in each group. Recurrence rates in ST and ET group were 2 and 11 % (p = 0.08). In the ET group, two patients with endoluminal cancer recurrence after complete eradication underwent esophagectomy. Age-adjusted overall survival was comparable. CONCLUSION: In high-volume esophageal centers, ST and ET provide equally safe and effective treatment for cT1a EAC in medically fit patients. While the results of this study provide a historical perspective and clearly demonstrate an evolution toward ET over time, the appropriate treatment modality is best selected in a multidisciplinary fashion with EMR providing the most accurate staging. In endoscopically treated patients, indefinite endoscopic follow-up required, however, standardized long-term follow-up protocols are needed.


Assuntos
Adenocarcinoma/cirurgia , Esôfago de Barrett/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagoscopia , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Esofágicas/patologia , Esofagectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Equipe de Assistência ao Paciente
7.
Thorac Surg Clin ; 25(4): 471-83, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26515947

RESUMO

Esophagectomy remains a key component of treatment for esophageal cancer and is also required in certain benign conditions. The functional sequelae of esophageal resection and reconstruction have taken on increasing importance due to the impact on long-term patient quality of life. Surgeons should be committed to a meticulous approach to conduit construction, avoid anastomoses in the mid and lower chest, and should also commit to careful long-term functional follow-up in their postesophagectomy patient population. Operative strategies to minimize functional disorders have been developed and all surgeons should have a structured approach to dealing with functional issues when they occur.


Assuntos
Gerenciamento Clínico , Transtornos da Motilidade Esofágica/terapia , Esofagectomia/efeitos adversos , Cuidados Pós-Operatórios/métodos , Anastomose Cirúrgica/efeitos adversos , Transtornos da Motilidade Esofágica/etiologia , Neoplasias Esofágicas/cirurgia , Humanos
8.
J Thorac Cardiovasc Surg ; 147(4): 1169-75; discussion 1175-7, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24507406

RESUMO

OBJECTIVE: Successful pulmonary wedge resection for early-stage non-small cell lung cancer requires a pathologically confirmed negative margin. To date, however, no clear evidence is available regarding whether an optimal margin distance, defined as the distance from the primary tumor to the closest resection margin, exists. Toward addressing this gap, we investigated the relationship between the margin distance and local recurrence risk. METHODS: We reviewed all adult patients who had undergone wedge resection for small (≤2 cm) non-small cell lung cancer from January 2001 to August 2011, with follow-up through to December 31, 2011. The exclusion criteria included other active noncutaneous malignancies, bronchoalveolar carcinomas, lymph node or distant metastases at diagnosis, large cell cancer, adenosquamous cancer, multiple, multifocal, and/or metastatic disease, and previous chemotherapy or radiotherapy. Using Cox regression analysis, we examined the relationship between the margin distance and interval to local recurrence, adjusting for chronic obstructive pulmonary disease, forced expiratory volume in 1 second, smoking, diabetes, tumor size, tumor location, surgeon, open versus video-assisted thoracoscopic surgery, and whether the lymph nodes were sampled. RESULTS: Of 557 consecutive adult patients, 479 met our inclusion criteria. The overall, unadjusted 1- and 2-year local recurrences rate was 5.7% and 11.0%, respectively. From the adjusted analyses, an increased margin distance was significantly associated with a lower risk of local recurrence (P = .033). Patients with a 10-mm margin distance had a 45% lower local recurrence risk than those with a 5-mm distance (hazard ratio, 0.55; 95% confidence interval, 0.35-0.86). Beyond 15 mm, no evidence of additional benefit was associated with an increased margin distance. CONCLUSIONS: In wedge resection for small non-small cell lung cancer, increasing the margin distance ≤15 mm significantly decreased the local recurrence risk, with no evidence of additional benefit beyond 15 mm.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Pneumonectomia , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonectomia/métodos , Estudos Retrospectivos
9.
J Vasc Access ; 15(1): 22-4, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24043327

RESUMO

PURPOSE: Peripheral artery aneurysms proximal to a long-standing arteriovenous (AV) fistula can be a serious complication. It is important to be aware of this and manage it appropriately. METHODS: Vascular access nurses input all data regarding patients undergoing dialysis access procedures into a securely held database prospectively. This was retrospectively reviewed to identify cases of brachial artery aneurysms over the last 3 years. RESULTS: In Morriston Hospital, around 200 forearm and arm AV fistulas are performed annually for vascular access in renal dialysis patients. Of these, approximately 15 (7.5%) are ligated. Three patients who had developed brachial artery aneurysms following AV fistula ligation were identified. All 3 patients had developed brachial artery aneurysms following ligation of a long-standing brachio-cephalic AV fistula. Two patients presented with pain and a pulsatile mass in the arm, and one presented with pins and needles and discoloration of fingertips. Two were managed with resection of the aneurysm and reconstruction with a reversed long saphenous vein interposition graft, the third simply required ligation of a feeding arterial branch. CONCLUSIONS: True aneurysm formation proximal to an AV fistula that has been ligated is a rare complication. There are several reasons for why these aneurysms develop in such patients, the most plausible one being the increase in blood flow and resistance following ligation of the AV fistula. Of note, all the patients in this study were on immunosuppressive therapy following successful renal transplantation. Vigilance by the vascular access team and nephrologists is paramount to identify those patients who may warrant further evaluation and investigation by the vascular surgeon.


Assuntos
Aneurisma/etiologia , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Artéria Braquial/cirurgia , Diálise Renal , Extremidade Superior/irrigação sanguínea , Adulto , Idoso , Aneurisma/diagnóstico , Aneurisma/fisiopatologia , Aneurisma/cirurgia , Artéria Braquial/diagnóstico por imagem , Artéria Braquial/fisiopatologia , Feminino , Humanos , Transplante de Rim , Ligadura , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Veia Safena/transplante , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , País de Gales
10.
J Surg Oncol ; 108(5): 315-9, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24037974

RESUMO

Minimal invasive surgery is an excellent approach for the diagnosis and treatment of a wide range of thoracic disorders that previously required sternotomy or open thoracotomy. The notable benefits of minimal invasive surgery to patients include less postoperative pain, fewer operative and post-operative major complications, shortened hospital stay, faster recovery times, less scarring, less stress on the immune system, smaller incision, and for some procedures reduced operating time and reduced costs.


Assuntos
Neoplasias Pulmonares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Humanos , Pneumonectomia , Radiocirurgia , Robótica , Cirurgia Torácica Vídeoassistida , Tomografia Computadorizada por Raios X
11.
Ann Thorac Surg ; 92(5): 1819-23; discussion 1824-5, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22051277

RESUMO

BACKGROUND: We evaluated a cohort of patients who underwent resection for small (2 cm or less) non-small cell lung cancer (NSCLC) to determine if there is an association between extent of resection (lobar versus sublobar resection) and local recurrence or survival. METHODS: We reviewed 468 consecutive patients who underwent resection for small NSCLC at our institution between 2000 and 2005. We excluded patients who had neoadjuvant therapy, active noncutaneous malignancies, pure bronchioalveolar carcinoma, lymph node (n = 53) or distant metastases at diagnosis, or multicentric cancers. Clinicopathologic data, recurrence, and vital status as of June 15, 2010, were retrieved. Overall and recurrence-free survival from surgery rates were assessed. RESULTS: Two hundred thirty-eight patients underwent resection for primary solitary small NSCLC. Lobectomy (n = 84) was associated with longer overall (p = 0.0027) and recurrence-free (p = 0.0496) survival. Patients who underwent sublobar resection were older (p < 0.0001) and had worse pulmonary function (p < 0.0014). While there was a trend toward increased rate of local recurrence for sublobar resection (16% versus 8%, p = 0.1117), there was no difference in distant recurrence. Moreover, when lymph nodes were sampled with sublobar resection, local recurrence rate and overall and recurrence-free survival distributions were similar to those for lobectomy. CONCLUSIONS: Sublobar resection is reasonable in older patients with limited cardiopulmonary function. For healthy patients, however, lobectomy remains the standard therapy, with sublobar resection with lymph node sampling representing an alternative to consider. These findings support continued effort to conduct a randomized trial of lobar versus sublobar resection, such as CALGB 140503.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Taxa de Sobrevida
12.
Pediatr Blood Cancer ; 55(3): 520-4, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20658624

RESUMO

BACKGROUND: Measuring the quality of life or performance status in pediatric neurooncology has proven a challenge. Here, we report in a treatment protocol for pediatric patients with high-grade glioma and diffuse intrinsic pontine glioma. PROCEDURE: The Fertigkeitenskala Münster-Heidelberg (FMH) is a 56-item quantitative measure of health status. The number of yes answers is transformed to age-dependent percentiles. Physicians were also asked the patients' health status by their own judgment on a 1-5 scale: normal, mild handicap, age-normal activity severely reduced but patient not in bed, in bed, and in ICU. RESULTS: Assessments were available from 50 of 97 eligible patients. For 22 patients both questionnaire and the physicians score obtained. At the beginning of the treatment, only 5 patients scored over 40 FMH%, and 4 of these survived. Of 16 patients who initially scored less than 40 FMH%, 15 died. During later assessments, most FMH measures became gradually worse. FMH scores improved in three patients. The physician's judgment was documented at diagnosis and during treatment (n = 50). Per physician, 22% of the patients were normal before chemotherapy, decreasing to 16% in the middle of the protocol. At diagnosis only 16% of patients had severely reduced activity, which increased to 30.6% in the middle of the protocol. The FMH% correlated well with the physicians' judgments (P < 0.005). CONCLUSION: The FMH scale is easily obtained and provides a valid assessment of health status. Patients with poor performance at diagnosis had a poorer prognosis.


Assuntos
Atividades Cotidianas , Neoplasias Encefálicas/fisiopatologia , Glioma/fisiopatologia , Nível de Saúde , Qualidade de Vida , Inquéritos e Questionários , Adolescente , Neoplasias do Tronco Encefálico/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino
13.
Surg Oncol ; 16(2): 85-98, 2007 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-17560103

RESUMO

BACKGROUND: The aim was to conduct a systematic review of the literature on the subject of laparoscopic gastrectomy (LG) and determine the relative merits of laparoscopic (LG) and open gastrectomy (OG) for gastric carcinoma. MATERIAL AND METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified individual retrospective and prospective series on LG (proximal, distal and total). Furthermore, all clinical trials that compared LG and OG published in the English language between January 1990 and the end of December 2006 were also identified. A large number of outcome variables were analysed for individual series and comparative trials between LG and OG and results discussed and tabulated. RESULTS: The majority of the literature is published from Japan showing both oncological adequacy and safety of LG. The majority of early series and comparative studies have utilized laparoscopic resection for early and distal gastric cancer. However, with increasing advanced laparoscopic experience, advancement in digital technology and improvement in instrumentation, more advanced gastric cancers and more extensive procedures such as laparoscopic-assisted total gastrectomy and laparoscopy-assisted D2 dissection are becoming more common. To date lymph node harvesting, resection margins and complication rates seem to be equivalent to open procedures. Furthermore, the earlier fears of port-site metastases have not been borne out. CONCLUSIONS: The available data suggests that LG seems to be associated with quicker return of gastrointestinal function, faster ambulation, earlier discharge from hospital, and comparable complications and recurrence rate to OG. However, the operating time for LG remains significantly longer compared to its open counterpart, although with experience it is achieving parity with OG. However, the majority of the comparative trials (if not all) probably do not have the power to detect differences in the outcome. As far as the RCT's (LG vs. OG) are concerned, the numbers of patients in such trials are small and the majority of patients were operated upon for early distal gastric cancer and, therefore, any meaningful conclusions regarding the advantages or disadvantages of LG for both the ECGs and extensive and advanced gastric tumours are difficult to justify.


Assuntos
Laparoscopia , Neoplasias Gástricas/cirurgia , Ensaios Clínicos como Assunto , Gastrectomia , Mucosa Gástrica/cirurgia , Humanos
15.
Int Semin Surg Oncol ; 4: 9, 2007 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-17391535

RESUMO

BACKGROUND: The best possible treatment of metastatic high grade large duodenal GIST is controversial. Surgery (with or without segmental organ resection) remains the principal treatment for primary and recurrent GIST. However, patients with advanced duodenal GIST have a high risk of early tumour recurrence and short life expectancy. METHOD: We present a case of a young man treated with a combined modality of surgery and imatinib for an advanced duodenal GIST. RESULTS: He remains asymptomatic and disease free 42 months following this combined approach. CONCLUSION: Treatment with imatinib has dramatically improved the outlook for patients with advanced, unresectable and/or metastatic disease.

16.
ANZ J Surg ; 76(3): 130-2, 2006 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-16626349

RESUMO

BACKGROUND: Seventeen independent risk factors were examined using multivariate logistic regression analysis to develop a profile of patients most likely at risk from iatrogenic gall bladder perforation (IGBP) during laparoscopic cholecystectomy. METHODS: Since 1989, a prospectively maintained database on 856 (women, 659; men, 197) consecutive laparoscopic cholecystectomies by a single surgeon (R. J. F.) was analysed. The mean age was 48 years (range, 17-94 years). The mean operating time was 88 min (range, 25-375 min) and the mean postoperative stay was 1 day (range, 1-24 days). There were 311 (women, 214; men, 97) IGBP. Seventeen independent variables, which included sex, race, history of biliary colic, dyspepsia, history of acute cholecystitis, acute pancreatitis and jaundice, previous abdominal surgery, previous upper abdominal surgery, medical illness, use of intraoperative laser or electrodiathermy, performance of intraoperative cholangiogram, positive intraoperative cholangiogram, intraoperative common bile duct exploration, presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively and success of the operation, were analysed using multivariate logistic regression for predicting IGBP. RESULTS: Multivariate logistic regression analysis against all 17 predictors was significant (chi(2) = 94.5, d.f. = 17, P = 0.0001), and the variables male sex, history of acute cholecystitis, use of laser and presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively were individually significant (P < 0.05) by the Wald chi(2)-test. CONCLUSION: Laparoscopic cholecystectomy, using laser, in a male patient with a history of acute cholecystitis or during an acute attack of cholecystitis is associated with a significantly higher incidence of IGBP.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Vesícula Biliar/lesões , Doença Iatrogênica/epidemiologia , Complicações Intraoperatórias/epidemiologia , Adolescente , Adulto , Idoso de 80 Anos ou mais , Colecistite Aguda/cirurgia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Fatores de Risco
17.
Breast J ; 12(2): 168-9, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16509844

RESUMO

Necrotizing fasciitis is a potentially fatal condition that can affect any part of the body. It can occur after trauma, around foreign bodies in surgical wounds, or can be idiopathic. We describe a case of necrotizing fasciitis involving the breast following an initial debridement of an inflammatory lesion.


Assuntos
Doenças Mamárias/patologia , Fasciite Necrosante/patologia , Doenças Mamárias/etiologia , Doenças Mamárias/cirurgia , Fasciite Necrosante/etiologia , Fasciite Necrosante/cirurgia , Feminino , Humanos , Inflamação , Pessoa de Meia-Idade , Pós-Menopausa
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