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1.
Vasc Endovascular Surg ; 54(1): 36-41, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31570064

RESUMO

OBJECTIVES: Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients. METHODS: The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis. RESULTS: From 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries (P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002). CONCLUSION: Traumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.


Assuntos
Veias Hepáticas/lesões , Veia Porta/lesões , Lesões do Sistema Vascular/epidemiologia , Adolescente , Adulto , Criança , Bases de Dados Factuais , Feminino , Veias Hepáticas/diagnóstico por imagem , Veias Hepáticas/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Veia Porta/diagnóstico por imagem , Veia Porta/cirurgia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Adulto Jovem
2.
HPB (Oxford) ; 21(11): 1577-1584, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31040065

RESUMO

BACKGROUND/PURPOSE: Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD. METHODS: Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h. RESULTS: A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001). CONCLUSION: There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.

5.
Pancreas ; 46(7): 898-903, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28697130

RESUMO

OBJECTIVES: Literature addressing the significance of lymph node positivity in the management of nonfunctional pancreatic neuroendocrine tumors (PNETs) is conflicting. METHODS: The National Cancer Data Base was queried for patients who underwent surgical resection of nonfunctional PNETs between 1998 and 2011. Clinical data and overall survival were analyzed using χ and Cox proportional hazards regression. Multiple imputation was used as a comparative analysis because of the high number of patients missing data on tumor grade. RESULTS: Two thousand seven hundred thirty-five patients were identified. The overall incidence of lymph node metastasis was 51%. In the subset of patients with grade 1 tumors less than 1 cm, 24% had positive lymph nodes. Overall median survival for patients with negative lymph nodes was 11 years compared with 8 years for lymph node-positive patients (P < 0.001). On multivariate survival analysis, tumor grade, distant metastases, regional lymph node involvement, positive surgical margins, male sex, and older age were predictive of decreased overall survival. CONCLUSIONS: Lymph node positivity was associated with decreased overall survival. The incidence of lymph node involvement in resected low-grade tumors less than 1 cm is higher than previously reported. Patients selected for resection of PNETs should be offered lymphadenectomy for staging.


Assuntos
Linfonodos/patologia , Tumores Neuroendócrinos/cirurgia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Tumores Neuroendócrinos/patologia , Neoplasias Pancreáticas/patologia
6.
Surg Innov ; 24(5): 492-498, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28643605

RESUMO

INTRODUCTION: A novel 3-dimensional (3D) guidance system was developed to aid accurate needle placement during ablation. METHODS: Five novices and 5 experienced hepatobiliary surgeons were recruited. Using an agar block with analog tumor, participants targeted under 4 conditions: in-line with the ultrasound plane using ultrasound, in-line using 3D guidance, 45° off-axis using ultrasound, and off-axis using 3D guidance. Time to target the tumor, number of withdrawals, and the National Aeronautics and Space Administration Task Load Index were collected. Initial and final parameters for each of the conditions were compared using a within-subjects paired t test. RESULTS: A significant reduction was seen in the number of required withdrawals in all situations when using the 3D guidance (0.75 vs 3.65 in-line and 0.25 vs 3.6 for off-axis). Mental workload was significantly lower when using 3D guidance compared with ultrasound both for novices (29.85 vs 41.03) and experts (31.98 vs 44.57), P < .001 for both. The only difference in targeting time between first and last attempt was in the novice group during off-axis targeting using 3D guidance (115 vs 32.6 seconds, P = .03). CONCLUSION: Though 3D guidance appeared to decrease time to target, this was not statistically significant likely as a result of lack of power in our trial. Three-dimensional guidance did reduce the number of required withdrawals, potentially decreasing complications, as well as mental workload after proficiency was achieved. Furthermore, novices without experience in ultrasound were able to learn targeting with the 3D guidance system at a faster pace than targeting with ultrasound alone.


Assuntos
Técnicas de Ablação/métodos , Imagem Tridimensional/métodos , Laparoscopia/métodos , Neoplasias , Cirurgiões/educação , Cirurgia Assistida por Computador/métodos , Humanos , Curva de Aprendizado , Neoplasias/diagnóstico por imagem , Neoplasias/cirurgia , Análise e Desempenho de Tarefas
7.
Ann Surg Oncol ; 24(7): 2015-2022, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28299507

RESUMO

INTRODUCTION: Current literature addressing the treatment of solid pseudopapillary neoplasms (SPNs) of the pancreas is limited, particularly for patients with distant metastases. We aimed to define predictive indicators of survival in a large series of patients and assess the outcome of patients with distant metastases. METHODS: The National Cancer Database was queried for patients diagnosed with SPNs of the pancreas between 1998 and 2011. Single predictor univariate analyses were performed on variables including demographics, tumor characteristics, and surgery outcomes, and multivariate Cox proportional hazards survival analysis was then completed with backward elimination. RESULTS: Overall, 340 patients were identified: 82% were female, median age was 39 years, and 84% had no comorbidities. Patients undergoing any type of surgical resection experienced long-term survival (85% 8-year survival). Patients undergoing surgical resection (n = 296) had superior survival (hazard ratio [HR] 21 for no surgery, p < 0.0001), as did patients treated at academic centers and those with private insurance (HR 3.9, p = 0.009; HR 4.9, p = 0.007). Sex, age, tumor size, presence of lymph node metastases, positive surgical margins, and presence of distant metastases were not significant predictors of survival in multivariate analysis. Of 24 patients with distant metastases, seven were treated surgically and experienced long-term survival similar to that of patients without metastases treated surgically (HR 2, p = 0.48). CONCLUSION: SPNs of the pancreas are rare neoplasms with excellent overall survival; however, in a low number of patients they metastasize. Of the few patients with metastatic disease selected for resection, most experienced long-term survival.


Assuntos
Carcinoma Papilar/secundário , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/patologia , Adulto , Carcinoma Papilar/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Invasividade Neoplásica , Metástase Neoplásica , Neoplasias Pancreáticas/cirurgia , Estudos Prospectivos , Taxa de Sobrevida , Resultado do Tratamento , Carga Tumoral
8.
HPB (Oxford) ; 19(6): 508-514, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28233672

RESUMO

BACKGROUND: Fistula Risk Score (FRS) is a previously developed tool to assess the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD). METHODS: Prospectively collected databases from 4 university affiliated and non-affiliated HPB centers in United States and Canada were used. The influence of individual baseline characteristics, FRS and FRS group on CR-POPF was assessed in univariate and multivariate analyses. FRS calculator performance was assessed using a C-statistic. RESULTS: 444 patients were identified. Pathology, soft pancreas texture and pancreatic duct size were associated with CR-POPF rates (p < 0.001 for each); EBL was not (p = 0.067). The negligible risk group consisted of 50 (11.3%) patients, low risk of 118 (26.6%), moderate 234 (52.7%) and high risk group of 42 (9.5%) patients. The overall rate of CR-POPF was 20%. Of the patients in the negligible risk group, 2% developed CR-POPF, 13.6% of the low risk, 23.1% moderate and 42.9% in the high risk group (p < 0.001). Overall C-statistic was 0.719. CONCLUSION: FRS is robust and able to stratify the risk of developing CR-POPF following PD in diverse North American academic and non-academic institutions. The FRS should be used in research and to guide clinical management of patients post PD in these institutions.


Assuntos
Técnicas de Apoio para a Decisão , Gastroenterologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Canadá , Distribuição de Qui-Quadrado , Tomada de Decisão Clínica , Bases de Dados Factuais , Gastroenterologia/normas , Humanos , Modelos Logísticos , Análise Multivariada , Fístula Pancreática/diagnóstico , Pancreaticoduodenectomia/normas , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Estados Unidos
9.
J Immunother Cancer ; 4: 45, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27532020

RESUMO

BACKGROUND: Preclinical studies have shown synergy between radiation therapy and immunotherapy. However, in almost all preclinical models, radiation is delivered in single doses or short courses of high doses (hypofractionated radiation). By contrast in most clinical settings, radiation is delivered as standard small daily fractions of 1.8-2 Gy to achieve total doses of 50-54 Gy (fractionated radiation). We do not yet know the optimal dose and scheduling of radiation for combination with chemotherapy and immunotherapy. METHODS: To address this, we analyzed the effect of neoadjuvant standard fractionated and hypofractionated chemoradiation on immune cells in patients with locally advanced and borderline resectable pancreatic adenocarcinoma. RESULTS: We found that standard fractionated chemoradiation resulted in a significant and extended loss of lymphocytes that was not explained by a lack of homeostatic cytokines or response to cytokines. By contrast, treatment with hypofractionated radiation therapy avoided the loss of lymphocytes associated with conventional fractionation. CONCLUSION: Hypofractionated neoadjuvant chemoradiation is associated with reduced systemic loss of T cells. TRIAL REGISTRATION: ClinicalTrials.gov NCT01342224, April 21, 2011; NCT01903083, July 2, 2013.

10.
Am J Surg ; 211(5): 871-6, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27046794

RESUMO

BACKGROUND: Preoperative risk stratification for postoperative pancreatic fistula in patients undergoing distal pancreatectomy is needed. METHODS: Risk factors for postoperative pancreatic fistula in 220 consecutive patients undergoing distal pancreatectomy at 2 major institutions were recorded retrospectively. Gland density was measured on noncontrast computed tomography scans (n = 101), and histologic scoring of fat infiltration and fibrosis was performed by a pathologist (n = 120). RESULTS: Forty-two patients (21%) developed a clinically significant pancreatic fistula within 90 days of surgery. Fat infiltration was significantly associated with gland density (P = .0013), but density did not predict pancreatic fistula (P = .5). Recursive partitioning resulted in a decision tree that predicted fistula in this cohort with a misclassification rate less than 15% using gland fibrosis (histology), density (HU), margin thickness (cm), and pathologic diagnosis. CONCLUSIONS: This multicenter study shows that no single perioperative factor reliably predicts postoperative pancreatic fistula after distal pancreatectomy. A decision tree was constructed for risk stratification.


Assuntos
Pâncreas/patologia , Pancreatectomia/efeitos adversos , Fístula Pancreática/etiologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/cirurgia , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Biópsia por Agulha , Estudos de Coortes , Feminino , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Pâncreas/cirurgia , Pancreatectomia/métodos , Fístula Pancreática/fisiopatologia , Fístula Pancreática/cirurgia , Neoplasias Pancreáticas/mortalidade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/cirurgia , Valor Preditivo dos Testes , Cuidados Pré-Operatórios/métodos , Prognóstico , Curva ROC , Estudos Retrospectivos , Risco Ajustado , Taxa de Sobrevida , Resultado do Tratamento
11.
HPB (Oxford) ; 18(1): 21-8, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26776847

RESUMO

BACKGROUND: Total pancreatectomy is infrequently performed for pancreatic cancer. Perceived operative mortality and questionable survival benefit deter many surgeons. Clinical outcomes, described in single-center series, remain largely unknown. METHODS: The National Cancer Database was queried for cases of pancreatic ductal adenocarcinoma undergoing total pancreatectomy (1998-2011). Univariate survival analyses were performed for 21 variables: demographic (8), tumor characteristics (5), surgery outcomes (6), and adjuvant therapy (2). The Log-rank test of differences in Kaplan-Meier survival curves was used for categorical variables. Variables with p < 0.05 were included in a multivariate analysis. Cox proportional hazards regression was used to analyze continuous variables and multivariate models. RESULTS: 2582 patients with staging and survival data made up the study population. 30-day mortality was 5.5%. Median overall survival was 15 months, with 1, 3, and 5-year survival rates of 60%, 22%, and 13%, respectively. Age, facility type, tumor size and grade, lymph node positivity, margin positivity, and adjuvant therapy significantly impacted survival in multivariate analysis. CONCLUSION: Although total pancreatectomy is a reasonable option for selected patients with pancreatic ductal adenocarcinoma, survival of the entire group is limited. Operative mortality is improved from prior reports. Greater survival benefits were seen in younger patients with smaller, node negative tumors resected with negative margins in academic research centers.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Centros Médicos Acadêmicos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/secundário , Bases de Dados Factuais , Feminino , Humanos , Estimativa de Kaplan-Meier , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Pancreatectomia/efeitos adversos , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Seleção de Pacientes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Carga Tumoral , Estados Unidos
12.
HPB (Oxford) ; 18(1): 79-87, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26776855

RESUMO

INTRODUCTION: Routine lymphadenectomy in the surgical treatment of intrahepatic cholangiocarcinoma (ICC) is not routinely performed. We aim to define predictive indicators of survival in patients with positive lymph nodes. METHODS: The National Cancer Data Base (NCDB) was queried for patients who underwent major hepatectomy for ICC between 1998 and 2011. Clinical and pathologic data were assessed using uni- and multi-variate analyses. A sub-analysis was performed on the 160 patients with positive lymph nodes. RESULTS: Of 849 patients with lymph node data, 57% had at least one lymph node examined. Median survival for lymph node negative patients was 37 months versus 15 months for lymph node positive patients. In lymph node positive patients, poorer survival was associated with not receiving chemotherapy (HR 1.83, p = 0.003), tumor size > 5 cm (p = 0.029), and older age (p < 0.0001). Lymph node positive patients age less than 45 had a median survival of 27 months. CONCLUSIONS: Overall survival in patients with lymph node metastases from ICC is poor. Adjuvant therapy was associated with a longer survival in lymph node positive patients, although prospective data are needed. Routine lymphadenectomy should be strongly considered to provide prognostic information and guidance for adjuvant therapy.


Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Colangiocarcinoma/cirurgia , Hepatectomia , Excisão de Linfonodo , Linfonodos/cirurgia , Adulto , Idoso , Neoplasias dos Ductos Biliares/mortalidade , Neoplasias dos Ductos Biliares/patologia , Colangiocarcinoma/mortalidade , Colangiocarcinoma/secundário , Bases de Dados Factuais , Feminino , Hepatectomia/efeitos adversos , Hepatectomia/mortalidade , Humanos , Estimativa de Kaplan-Meier , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/mortalidade , Linfonodos/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
13.
HPB (Oxford) ; 17(5): 454-60, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25580988

RESUMO

INTRODUCTION: With technological advances, questions arise regarding how to best fit newer treatment modalities, such as transarterial therapies, into the treatment algorithm for patients with hepatocellular carcinoma (HCC). METHODS: Between 2005 and 2011, 128 patients initially treated with transarterial radioembolization or chemoembolization using drug-eluting beads were identified. The response was graded retrospectively. Toxicity was measured 1, 3, and 6 months after the first and last treatments. RESULTS: Sixty-five patients (53%) were advanced stage. Twenty patients (16%) had an initial complete response, but with additional treatments, this was increased to 46 (36%). Patients with a complete response as their best response to treatment had a median survival [95% confidence interval (CI)] of 5.77 (2.58, upper limit not yet reached) years, significantly longer than those whose best response was a partial response, 1.22 (0.84, 2.06) years and those with stable disease as their best response, 0.34 (0.29, 0.67) years. Repeated treatments did not increase toxicity. DISCUSSION: This retrospective review of patients treated for intermediate and advanced stage HCC revealed a significant survival advantage in patients who achieved a complete response. These data support use of a multi-modality approach to intermediate and advanced stage HCC, combining liver-directed treatments as necessary to achieve a complete response.


Assuntos
Carcinoma Hepatocelular/terapia , Terapia Combinada/métodos , Neoplasias Hepáticas/terapia , Carcinoma Hepatocelular/mortalidade , Quimioembolização Terapêutica/métodos , Feminino , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
14.
Surg Oncol Clin N Am ; 24(1): 97-119, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25444471

RESUMO

A wide array of ablation technologies, in addition to the progressive sophistication of imaging technologies and percutaneous, laparoscopic, and open surgical techniques, have allowed us to expand treatment options for patients with liver tumors. In this article, technical considerations of chemical and thermal ablations and their application in hepatic oncology are reviewed.


Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/cirurgia , Ablação por Cateter/métodos , Colangiocarcinoma/cirurgia , Neoplasias Hepáticas/cirurgia , Neoplasias dos Ductos Biliares/patologia , Ductos Biliares Intra-Hepáticos/patologia , Colangiocarcinoma/patologia , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/secundário
15.
HPB (Oxford) ; 16(4): 350-6, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24112766

RESUMO

OBJECTIVES: This study investigated the impact of neoadjuvant radiation therapy (XRT) on postoperative outcomes following pancreaticoduodenectomy for pancreatic cancer. METHODS: The American College of Surgeons National Quality Improvement Program database was queried for the period 2005-2010 to assess complication rates following pancreaticoduodenectomy for pancreatic cancer. Two groups of patients were identified, comprising those who received neoadjuvant XRT and those who did not (control group). RESULTS: A total of 4416 patients were identified, including 200 in the XRT group and 4216 in the control group. There were differences in patient characteristics between the groups, including in age, hypertension and bilirubin level. Despite the fact that weight loss was more common, median operative time was longer (423 min versus 368 min; P < 0.001), and vascular reconstruction was more commonly required (20.5% versus 8.4%; P < 0.001) in the XRT group. In addition, the XRT group had a shorter median hospital stay than the control group (9 days versus 10 days; P = 0.005). Mortality (3.0% versus 2.7%; P = 0.818) and morbidity (40.5% versus 37.6%; P = 0.404) rates were not influenced by neoadjuvant XRT. Blood transfusion rates were increased in the XRT group (13.0% versus 7.4%; P = 0.003). Severe complications were influenced by age >70 years, American Society of Anesthesiologists (ASA) class >2, preoperative sepsis, dyspnoea, weight loss, impaired functional status, peripheral vascular disease and operative time of >8 h. CONCLUSIONS: Neoadjuvant XRT is not associated with an increase in complications after pancreaticoduodenectomy.


Assuntos
Terapia Neoadjuvante , Neoplasias Pancreáticas/terapia , Pancreaticoduodenectomia , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/mortalidade , Duração da Cirurgia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/mortalidade , Seleção de Pacientes , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Radioterapia Adjuvante , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
16.
Surg Innov ; 21(4): 419-26, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24201739

RESUMO

BACKGROUND: The Explorer Minimally Invasive Liver (MIL) system uses imaging to create a 3-dimensional model of the liver. Intraoperatively, the system displays the position of instruments relative to the virtual liver. A prospective clinical study compared it with intraoperative ultrasound (iUS) in laparoscopic liver ablations. METHODS: Patients undergoing ablations were accrued from 2 clinical sites. During the procedures, probes were positioned in the standard fashion using iUS. The position was synchronously recorded using the Explorer system. The distances from the probe tip to the tumor boundary and center were measured on the ultrasound image and in the corresponding virtual image captured by the Explorer system. RESULTS: Data were obtained on the placement of 47 ablation probes during 27 procedures. The absolute difference between iUS and the Explorer system for the probe tip to tumor boundary distance was 5.5 ± 5.6 mm, not a statistically significant difference. The absolute difference for probe tip to tumor center distance was 8.6 ± 7.0 mm, not statistically different from 5 mm. DISCUSSION: The initial clinical experience with the Explorer MIL system shows a strong correlation with iUS for the positioning of ablation probes. The Explorer MIL system is a promising tool to provide supplemental guidance information during laparoscopic liver ablation procedures.


Assuntos
Ablação por Cateter/métodos , Hepatectomia/instrumentação , Laparoscopia/métodos , Cirurgia Assistida por Computador/métodos , Ultrassonografia Doppler/métodos , Idoso , Feminino , Seguimentos , Hepatectomia/métodos , Humanos , Cuidados Intraoperatórios/métodos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Prospectivos , Medição de Risco , Resultado do Tratamento
17.
Arch Surg ; 147(9): 864-9, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22987183

RESUMO

OBJECTIVES: To compare the outcomes of umbilical hernia repair in patients with and without signs of portal hypertension, such as esophageal varices or ascites; to assess the effect of emergency surgery on complication rates; and to identify predictors of postoperative mortality. DESIGN: Database search from January 1, 2005, through December 31, 2009. SETTING: North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program initiative. PATIENTS: We studied patients who underwent umbilical hernia repair. Those with congestive heart failure, disseminated malignant tumor, or chronic renal failure while undergoing dialysis were excluded. MAIN OUTCOME MEASURES: Preoperative variables and perioperative course were analyzed. Main outcome measures were morbidity and mortality after umbilical hernia repair. RESULTS: A total of 390 patients with ascites and/or esophageal varices formed the study group, and the remaining 22 952 patients formed the control group. The overall morbidity and mortality rates for the study group were 13.1% and 5.1%, whereas these rates were 3.9% and 0.1% for the control group, respectively (P < .001). For the study group, the mortality after elective repair among patients with a model for end-stage liver disease (MELD) score greater than 15 was 11.1% compared with 1.3% in patients with a MELD score of 15 or less. The patients with ascites and/or esophageal varices underwent emergency surgery more frequently than the control group (37.7% vs 4.9%; P < .001). Emergency surgery for the study group was associated with a higher morbidity than elective surgery (20.8% vs 8.3%; P < .001) but not a significantly higher mortality (7.4% vs 3.7%; P = .11). However, logistic regression analysis showed that age older than 65 years, MELD score higher than 15, albumin level less than 3.0 g/dL (to convert to grams per liter, multiply by 10), and sepsis at presentation were more predictive of postoperative mortality. CONCLUSIONS: Umbilical hernia repair in the presence of ascites and/or esophageal varices is associated with significant postoperative complication rates. Emergency surgery is associated with higher morbidity rates but not significantly higher mortality rates. Elective repair of umbilical hernia should be avoided for those with adverse predictors, such as age older than 65 years, MELD score higher than 15, and albumin level less than 3.0 g/dL.


Assuntos
Hérnia Umbilical/mortalidade , Hérnia Umbilical/cirurgia , Herniorrafia , Hipertensão Portal/mortalidade , Feminino , Hérnia Umbilical/complicações , Humanos , Hipertensão Portal/complicações , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Resultado do Tratamento
18.
Am J Surg ; 204(3): 332-8, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22464011

RESUMO

BACKGROUND: Despite considerable data focused on the morbidity of pancreaticoduodenectomy (PD), the financial impact of complications has been infrequently analyzed. This study evaluates the impact of the most common complications associated with PD on the cost of care. Additionally, we identified cost centers that were significantly affected by complications. METHODS: A retrospective analysis of a prospective database in a network of community-based teaching hospitals was performed. All patients (n = 145) who underwent PD were included for years 2005 to 2009. Of these, 144 had complete in-hospital cost data. Complications were assessed and classified into major and minor categories according to Dindo et al. Forty-nine cost centers were analyzed for their association with the cost of complications. Univariate and multivariate linear regression analyses were performed. Significance was reported for P < .05. RESULTS: The median cost for PD was $30,937. Patients with major complications had significantly higher median cost compared with those without ($56,224 vs $29,038; P < .001). Independent predictors of increased cost included reoperation; sepsis; pancreatic fistula; bile leak; delayed gastric emptying; and pulmonary, renal, and thromboembolic complications. Cost center analysis showed significant added charges for patients with major complications for blood bank ($1,018), clinical laboratory ($3,731), a computed tomography scan ($4,742), diagnostic imaging ($697), intensive care unit ($4,986), pharmacy ($33,850) and respiratory therapy ($1,090) (P < .05, all). CONCLUSIONS: This study identified the major complications of PD, which are significantly associated with a higher cost. Substantial cost center increases were associated with major complications, particularly in pharmacy ($33,850). Measures aimed at limiting complications through centralization of care or care pathways may reduce the overall cost of care for patients after pancreatic resection.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/economia , Complicações Pós-Operatórias/economia , Idoso , Análise de Variância , Bancos de Sangue/economia , Cuidados Críticos/economia , Diagnóstico por Imagem/economia , Custos de Medicamentos/estatística & dados numéricos , Feminino , Esvaziamento Gástrico , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/economia , Fístula Pancreática/etiologia , Complicações Pós-Operatórias/etiologia , Reoperação/economia , Terapia Respiratória/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sepse/economia , Sepse/etiologia , Tomografia Computadorizada por Raios X/economia , Estados Unidos
19.
Ann Surg Oncol ; 18(7): 1947-54, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21399885

RESUMO

BACKGROUND: There continues to be controversy surrounding the appropriate use of radiofrequency ablation (RFA) for the treatment of colorectal liver metastases (CRLM). This study analyzes outcomes data of CRLM patients who underwent laparoscopic RFA. Outcomes of patients determined to be technically resectable were compared to patients with unresectable disease. METHODS: Data from all patients with CRLM who underwent laparoscopic RFA between 1996 and 2006 were retrospectively reviewed. A blinded independent hepatobiliary-trained surgical oncologist reviewed preoperative diagnostic imaging studies to determine resectability. Outcomes data for patients with disease deemed anatomically resectable and unresectable were analyzed and compared. Survival was calculated by the Kaplan-Meier method. The log rank test was performed to assess significance in survival. RESULTS: A total of 113 patients who underwent laparoscopic RFA for CRLM were identified. Twelve patients who underwent concurrent hepatic resection were excluded. Of the remaining patients, 64 were determined to have disease that was be technically resectable and 37 unresectable as a result of tumor number and/or distribution. Median and 5-year survival of the potentially resectable group was 4.3years and 48.7%, compared to 2.2 years and 18.4% in the unresectable group (P = 0.002). Median disease-free survival in the resectable group was 15.0 months, compared to 16.4 months in the unresectable group (P = 0.796). No postoperative mortality was reported in the technically resectable group, and the rate of major complications was 3.1%. CONCLUSIONS: Laparoscopic RFA of resectable CRLM can produce comparable long-term survival to hepatic resection in carefully selected patients, with favorable morbidity and mortality.


Assuntos
Ablação por Cateter , Neoplasias Colorretais/cirurgia , Laparoscopia , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia/cirurgia , Idoso , Estudos de Coortes , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Terapia Combinada , Feminino , Seguimentos , Humanos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Cuidados Pré-Operatórios , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida , Tomografia Computadorizada por Raios X , Resultado do Tratamento
20.
HPB (Oxford) ; 13(4): 272-8, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21418133

RESUMO

INTRODUCTION: Selected patients with isolated breast cancer liver metastases (BCLM) may benefit from surgical management; however, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis. METHODS: Between 1998 and 2006, 17 patients diagnosed with BCLM were considered for surgical management (<4 tumours, tumour <4 cm in diameter and no/stable extrahepatic metastases). Peri-operative and outcomes data were analysed and compared. RESULTS: Eight patients were found to have extensive or untreatable disease on staging laparoscopy and intra-operative ultrasound (SL/IOUS). The remaining nine patients underwent surgical management [seven laparoscopic radiofrequency ablations (RFA) and two hepatic resections]. Median length of follow-up for patients treated surgically was 40.0 months, median disease-free survival (DFS) was 32.2 months and median time to disease progression was 17.7 months. Of the eight patients not amenable to surgery, median length of follow-up was 21.8 months. CONCLUSION: SL/IOUS prevented unnecessary laparotomy in half of the patients taken to the operating room for surgical treatment of BCLM. In patients with BCLM, SL/IOUS should be considered standard of care before surgical intervention. The small number of patients and short follow-up may be inadequate to determine the true value of surgical management in this group of patients with BCLM.


Assuntos
Neoplasias da Mama/patologia , Ablação por Cateter/métodos , Hepatectomia , Laparoscopia , Neoplasias Hepáticas/cirurgia , Adulto , Idoso , Neoplasias da Mama/mortalidade , Intervalo Livre de Doença , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Oregon , Seleção de Pacientes , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia
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