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1.
Plast Reconstr Surg ; 146(5): 588e-598e, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33141535

RESUMO

BACKGROUND: The authors conducted a cost-effectiveness analysis to answer the question: Which motion-preserving surgical strategy, (1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty, used for the treatment of wrist osteoarthritis, is the most cost-effective? METHODS: A simulation model was created to model a hypothetical cohort of wrist osteoarthritis patients (mean age, 45 years) presenting with painful wrist and having failed conservative management. Three initial surgical treatment strategies-(1) four-corner fusion, (2) proximal row carpectomy, or (3) total wrist arthroplasty-were compared from a hospital perspective. Outcomes included clinical outcomes and cost-effectiveness outcomes (quality-adjusted life-years and cost) over a lifetime. RESULTS: The highest complication rates were seen in the four-corner fusion cohort: 27.1 percent compared to 20.9 percent for total wrist arthroplasty and 17.4 percent for proximal row carpectomy. Secondary surgery was common for all procedures: 87 percent for four-corner fusion, 57 percent for proximal row carpectomy, and 46 percent for total wrist arthroplasty. Proximal row carpectomy generated the highest quality-adjusted life-years (30.5) over the lifetime time horizon, compared to 30.3 quality-adjusted life-years for total wrist arthroplasty and 30.2 quality-adjusted life-years for four-corner fusion. Proximal row carpectomy was the least costly; the mean expected lifetime cost for patients starting with proximal row carpectomy was $6003, compared to $11,033 for total wrist arthroplasty and $13,632 for four-corner fusion. CONCLUSIONS: The authors' analysis suggests that proximal row carpectomy was the most cost-effective strategy, regardless of patient and parameter level uncertainties. These are important findings for policy makers and clinicians working within a universal health care system.


Assuntos
Artrodese/economia , Artroplastia de Substituição/economia , Tratamentos com Preservação do Órgão/economia , Osteoartrite/cirurgia , Osteotomia/economia , Articulação do Punho/cirurgia , Adulto , Artrodese/métodos , Artroplastia de Substituição/métodos , Ossos do Carpo/cirurgia , Simulação por Computador , Análise Custo-Benefício , Feminino , Força da Mão/fisiologia , Custos Hospitalares , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Tratamentos com Preservação do Órgão/métodos , Osteoartrite/economia , Osteotomia/métodos , Amplitude de Movimento Articular/fisiologia , Resultado do Tratamento , Articulação do Punho/fisiologia
2.
Medicine (Baltimore) ; 99(46): e23110, 2020 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-33181678

RESUMO

Multilocular cystic renal neoplasm of low malignant potential (MCRNLMP) might be benefited from nephron-sparing surgery. Contrast-enhanced computed tomography is used for the diagnosis of MCRNLMP but contrast-enhanced ultrasound has lack of nephrotoxicity and several advantages over contrast-enhanced computed tomography and contrast-enhanced magnetic resonance. The purpose of the study was to compare diagnostic parameters of preoperative contrast-enhanced ultrasound against contrast-enhanced computed tomography for the detection of MCRNLMP in patients who faced curative surgery for complex cystic renal mass.Data regarding contrast-enhanced ultrasound, contrast-enhanced computed tomography, and clinicopathological results of 219 patients who underwent curative surgery for complex cystic renal mass (Bosniak classification III or IV) were retrospectively collected and analyzed. Bosniak classification for imaging modality and the 2016 WHO criteria for clinic pathology were used for detection of MCRNLMP.Contrast-enhanced ultrasound, contrast-enhanced computed tomography, and clinicopathology were detected 68, 66, and 67 as a MCRNLMP respectively. Contrast-enhanced ultrasound and contrast-enhanced computed tomography had 30.37% and 29.27% sensitivities for the detection of MCRNLMP. While 60% and 50% specificities respectively. Bosniak classification III (P = .045) and lower mean Hounsfield unit (P = .049) were associated with the prevalence of MCRNLMP. Contrast-enhanced computed tomography was detected 6 and 7, while contrast-enhanced ultrasound detected 3 and 2 complex cystic renal mass as false positive and false negative MCRNLMP respectively. A contrast-enhanced ultrasound had 0.011 to 1.0 diagnostic confidence and contrast-enhanced computed tomography had 0.045 to 0.983 diagnostic confidence for decision making of nephron-sparing surgeries.Contrast-enhanced ultrasound may have better visualization of MCRNLMP than contrast-enhanced computed tomography.Level of Evidence: III.


Assuntos
Carcinoma de Células Renais , Aumento da Imagem/métodos , Neoplasias Renais , Rim/diagnóstico por imagem , Compostos Organometálicos/farmacologia , Fosfolipídeos/farmacologia , Hexafluoreto de Enxofre/farmacologia , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia/métodos , Carcinoma de Células Renais/diagnóstico , Carcinoma de Células Renais/cirurgia , Tomada de Decisão Clínica , Pesquisa Comparativa da Efetividade , Meios de Contraste/farmacologia , Precisão da Medição Dimensional , Feminino , Humanos , Neoplasias Renais/diagnóstico , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Tratamentos com Preservação do Órgão/métodos
3.
Lancet Child Adolesc Health ; 4(11): 846-852, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33068550

RESUMO

For decades, radiotherapy with two opposing photon beams has been the standard technique used to cover the flank target volume in paediatric patients with renal tumours. Nowadays, many institutes are implementing advanced radiotherapy techniques that spare healthy tissue. To decrease the radiotherapy dose to healthy structures while preserving oncological efficacy, the conventional approach of flank irradiation has been adapted into a guideline for highly conformal flank target-volume delineation by paediatric radiation oncologists and representatives of the International Society of Paediatric Oncology's Renal Tumour Study Group (SIOP-RTSG) board during four live international consensus meetings. The consensus was refined by delineation exercises and videoconferences by ten collaborating paediatric radiation oncologists. The final guideline includes eight chronological steps to generate the tumour bed and clinical, internal, and planning target volumes, and it describes the optional use of surgical clips to optimise treatment planning. This guideline will be added into the radiotherapy guideline of the UMBRELLA SIOP-RTSG protocol for paediatric renal tumours to improve international consistency of highly conformal flank target-volume delineation.


Assuntos
Neoplasias Renais/radioterapia , Tratamentos com Preservação do Órgão/métodos , Radioterapia Conformacional , Criança , Consenso , Humanos , Neoplasias Renais/patologia , Guias de Prática Clínica como Assunto , Saúde Radiológica , Radioterapia Conformacional/métodos , Radioterapia Conformacional/tendências
4.
Medicine (Baltimore) ; 99(38): e22201, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957352

RESUMO

The purpose of our study was to evaluate the ocular survival and event-free survival after multimodal therapy for group D and E of retinoblastoma (RB). Enucleation of group D and E is controversial as the risks of chemotherapy must be weighed against the potential for vision.A 10-year retrospective study from one center of 86 patients with advanced intraocular disease defined as International Classification Retinoblastoma (ICRB) group "D" or "E." Cases with visible extraocular extension at diagnosis were excluded. Ocular survival and patient survival were assessed. Indirect ophthalmoscopy at examination under anesthesia to visualize the tumor was used to evaluate clinical response.The median onset age in 86 patients with group D or E eye was 16 months (1-167 months). There were 29 (34%) bilateral cases. Leukocoria was the most common presentation sign (61%). Chemoreduction was primarily used in the treatment of intraocular RB. Selective ophthalmic arterial injection (SOAI) was applied as a component of multimodal therapy in 34 of the 86 cases. The globe preservation rate in patients with group D or E eyes was 19%. Using chemoreduction for advanced eyes, more eyes are being preserved which enables 70% 5-year ocular survival in patients with group D eyes.In triaging appropriate patients, multidisciplinary strategy can reduce tumor size with chemoreduction and consolidate the regressed tumor with local ophthalmic therapy to ensure globe salvage.


Assuntos
Tratamentos com Preservação do Órgão/métodos , Neoplasias da Retina/terapia , Retinoblastoma/terapia , Antineoplásicos/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica , Pré-Escolar , Terapia Combinada , Enucleação Ocular , Feminino , Humanos , Lactente , Masculino , Radioterapia , Estudos Retrospectivos , Terapia de Salvação
5.
Medicine (Baltimore) ; 99(36): e21763, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899004

RESUMO

RATIONALE: Neonatal testicular torsion is a rare condition. There is no consensus about the optimal surgical treatment of neonatal testicular torsions. The salvage rate reported in literature remains poor. Discrimination of the onset of a neonatal testicular torsion seems to have an important impact of the salvage rate. Deliveries out of breech presentation have a risk for neonatal complications including neonatal genital birthtrauma. PATIENT CONCERNS: A newborn boy, who was delivered at 40 weeks of gestation out of breech presentation, showed shortly after birth, a painful discoloration and swelling of the scrotum. DIAGNOSIS: Clinical examination and ultrasound were highly suspicious for testicular torsion. INTERVENTION: Emergency surgery revealed a bilateral testicular torsion with dark coloration of both testicles. The testicles were detorted and left in situ. A bilateral orchidopexy was performed. OUTCOMES: Postoperative ultrasound showed reperfusion of both testicles and the boy was discharged from hospital. Follow-up after 2 months showed normal clinical examination and sonographically persistent perfusion of both testicles. Endocrinological investigations during minipuberty revealed normal hormonal values. LESSONS: We present this rare case in regard to the current literature and recommend close observation of newborns for genital trauma after delivery out of breech position. We encourage surgeons to carefully consider leaving the testicles in situ.


Assuntos
Traumatismos do Nascimento/cirurgia , Orquidopexia/métodos , Torção do Cordão Espermático/cirurgia , Apresentação Pélvica , Feminino , Humanos , Recém-Nascido , Masculino , Tratamentos com Preservação do Órgão/métodos , Gravidez
6.
Plast Reconstr Surg ; 146(2): 156e-164e, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32740578

RESUMO

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to reduce complications associated with the traditional technique. As an extension of a previously published randomized controlled trial, this study aims to clarify whether preservation of Scarpa fascia during abdominoplasty has an influence on scar quality or sensibility recovery. METHODS: This was a single-center clinical trial, involving 160 patients randomly assigned to one of two surgical procedures: classic full abdominoplasty (group A) and abdominoplasty with preservation of Scarpa fascia (group B). Patients were later convoked to assess scar quality and abdominal cutaneous sensibility. Scar quality was evaluated through the Patient and Observer Scar Assessment Scale. Cutaneous sensibility was measured on the upper and lower abdomen, using light touch, Semmes-Weinstein testing (5.07/10-g monofilament), and a 25-gauge needle. RESULTS: A total of 99 patients (group A, 54 patients; group B, 45 patients) responded to contact, with a mean follow-up time of 44 months. Concerning scar quality, Patient and Observer Scar Assessment Scale scores were similar between groups. On the upper abdomen, there was a statistically significant difference between groups on cutaneous sensibility, on the examination with the Semmes-Weinstein 5.07/10-g monofilament (group A, 79.6 percent; group B, 93.3 percent; p = 0.046) and pain (group A, 90.7 percent; group B, 100 percent; p = 0.044). No statistically significant differences were found between groups on the lower abdomen. A considerable proportion of patients (two-thirds) still presented sensibility alterations in the subumbilical area 3½ years after abdominoplasty. CONCLUSION: Scarpa fascia preservation during abdominoplasty does not influence scar quality, but it improves sensibility recovery in the supraumbilical area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Assuntos
Abdominoplastia/métodos , Cicatriz/diagnóstico , Tratamentos com Preservação do Órgão/métodos , Complicações Pós-Operatórias/diagnóstico , Tato/fisiologia , Parede Abdominal , Abdominoplastia/efeitos adversos , Adulto , Cicatriz/etiologia , Fáscia/inervação , Fasciotomia/efeitos adversos , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Índice de Gravidade de Doença , Pele/inervação , Resultado do Tratamento , Adulto Jovem
7.
Pediatr Blood Cancer ; 67(10): e28625, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32743978

RESUMO

BACKGROUND: Bilateral retinoblastoma (Rb) treatment remains a challenge for ophthalmologists and pediatric oncologists despite new therapeutic strategies for eye preservation. The purpose of this work is to evaluate treatment outcomes in patients who underwent eye salvage treatment at a single-center prior to the chemotherapy in situ era. PROCEDURE: We followed a cohort of 88 consecutive Rb patients diagnosed at Hospital Infantil de México between November 2000 and June 2014. Eye salvage treatment consisted of systemic chemotherapy plus focal therapy planned by a multidisciplinary team. Unresponsive tumors were treated with episcleral brachytherapy and external beam radiotherapy (EBRT). RESULTS: A total of 96 eyes underwent eye salvaging therapy. Seventy-eight eyes (81%) were salvaged. Seven patients (8%) required brachytherapy and 34 patients (39%) underwent EBRT. Thirty-three of 78 preserved eyes (42%) achieved normal visual acuity: 5/27 (20%) in radiated patients and 28/51 (61%) in nonradiated patients. Eight patients developed secondary primary malignancies; however, those treated with EBRT did not have a significantly increased risk when compared with nonirradiated patients (OR: 1.66; P = 0.492). The overall survival rate was 86% (95% CI, 76%-92%) after a mean follow-up of 10 years. CONCLUSIONS: Eye preservation, long-term tumor control, and functional visual acuity could be maintained in many child and adolescent Rb survivors. Our data suggest that ocular radiotherapy can be used as consolidation treatment when other recently developed therapies with potentially fewer side effects are not available. Multidisciplinary management of Rb is mandatory to obtain cancer control during eye salvage treatment.


Assuntos
Olho/efeitos dos fármacos , Olho/efeitos da radiação , Neoplasias Orbitárias/terapia , Tratamentos com Preservação do Órgão/métodos , Neoplasias da Retina/terapia , Retinoblastoma/terapia , Terapia de Salvação , Quimiorradioterapia/métodos , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , México , Neoplasias Orbitárias/patologia , Prognóstico , Neoplasias da Retina/patologia , Retinoblastoma/patologia , Acuidade Visual
8.
Obstet Gynecol ; 136(3): 466-469, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32769652

RESUMO

BACKGROUND: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, with uterine atony responsible in 80% of cases. In intractable cases, hysterectomy is the final treatment, but it has complications. Many doctors in developing countries with high maternal mortality rates from postpartum hemorrhage can perform cesarean deliveries but cannot perform hysterectomy. Patients with postpartum hemorrhage who need hysterectomy in these countries will die in such cases, whereas, if doctors know this simple, easily learned technique, such patients may survive. TECHNIQUE: Esike's technique is a uterine-compression method that uses supplies generally available at delivery hospitals. Six sutures are placed in the lower uterine segment, three anteriorly and three posteriorly. Starting with the middle sutures, the sutures are tied at the fundus with the help of an assistant to provide uterine compression. The more laterally placed sutures are then tied similarly, resulting in uterine compression and stoppage of postpartum hemorrhage. EXPERIENCE: Esike's technique was used in controlling life-threatening, uncontrollable postpartum hemorrhage in 18 women and was successful in 16 (89%) without requiring hysterectomy. CONCLUSION: Esike's technique is effective in controlling life-threatening postpartum hemorrhage and can be used in low-resource settings with commonly available supplies and performed by doctors with a common level of training.


Assuntos
Tratamentos com Preservação do Órgão/métodos , Hemorragia Pós-Parto/cirurgia , Técnicas de Sutura , Útero , Adulto , Feminino , Humanos , Gravidez , Resultado do Tratamento , Adulto Jovem
9.
Cochrane Database Syst Rev ; 8: CD013641, 2020 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-32813279

RESUMO

BACKGROUND: Robotic-assisted laparoscopic prostatectomy (RALP) is widely used to surgically treat clinically localized prostate cancer. It is typically performed using an approach (standard RALP) that mimics open retropubic prostatectomy by dissecting the so-called space of Retzius anterior to the bladder. An alternative, Retzius-sparing (or posterior approach) RALP (RS-RALP) has been described, which is reported to have better continence outcomes but may be associated with a higher risk of incomplete resection and positive surgical margins (PSM). OBJECTIVES: To assess the effects of RS-RALP compared to standard RALP for the treatment of clinically localized prostate cancer. SEARCH METHODS: We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to June 2020. We applied no restrictions on publication language or status. SELECTION CRITERIA: We included trials where participants were randomized to RS-RALP or standard RALP for clinically localized prostate cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently classified and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery six and 12 months after surgery, potency recovery 12 months after surgery, positive surgical margins (PSM), biochemical recurrence-free survival (BCRFS), and urinary and sexual function quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS: Our search identified six records of five unique randomized controlled trials, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. Mean age of participants was 64.6 years and mean prostate-specific antigen was 6.9 ng/mL. About 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1 % had cT2c disease. Primary outcomes RS-RALP probably improves continence within one week after catheter removal (risk ratio (RR) 1.74, 95% confidence interval (CI) 1.41 to 2.14; I2 = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at three months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06 to 1.68; I2 = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47 to 4.17; studies = 2; participants = 230; very low-certainty evidence). Secondary outcomes There is probably little to no difference in continence recovery at 12 months after surgery (RR 1.01, 95% CI 0.97 to 1.04; I2 = 0%; studies = 2; participants = 222; moderate-certainty evidence). Assuming 982 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 10 more men per 1000 (29 fewer to 39 more) reporting continence recovery.  We are very uncertain about the effect of RS-RALP on potency recovery 12 months after surgery (RR 0.98, 95% CI 0.54 to 1.80; studies = 1; participants = 55; very low-certainty evidence).  RS-RALP may increase PSMs (RR 1.95, 95% CI 1.19 to 3.20; I2 = 0%; studies = 3; participants = 308; low-certainty evidence) indicating a higher risk for prostate cancer recurrence. Assuming 129 per 1000 men undergoing standard RALP have positive margins, this corresponds to 123 more men per 1000 (25 more to 284 more) with PSMs. We are very uncertain about the effect of RS-RALP on BCRFS compared to standard RALP (hazard ratio (HR) 0.45, 95% CI 0.13 to 1.60; I2 = 32%; studies = 2; participants = 218; very low-certainty evidence). AUTHORS' CONCLUSIONS: Findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to six months after surgery. Continence outcomes at 12 months may be similar. Downsides of RS-RALP may be higher positive margin rates. We are very uncertain about the effect on BCRFS and potency outcomes. Longer-term oncologic and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach.


Assuntos
Tratamentos com Preservação do Órgão/métodos , Complicações Pós-Operatórias/prevenção & controle , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Incontinência Urinária/prevenção & controle , Idoso , Humanos , Calicreínas/sangue , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão/efeitos adversos , Ereção Peniana , Complicações Pós-Operatórias/epidemiologia , Antígeno Prostático Específico/sangue , Prostatectomia/efeitos adversos , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Incontinência Urinária/epidemiologia
11.
J Am Acad Orthop Surg ; 28(22): 914-922, 2020 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-32796370

RESUMO

Cartilage injuries in the knee are common and can occur in isolation or in combination with limb malalignment, meniscus, ligament, and bone deficiencies. Each of these problems must be addressed to achieve a successful outcome for any cartilage restoration procedure. If nonsurgical management fails, surgical treatment is largely based on the size and location of the cartilage defect. Preservation of the patient's native cartilage is preferred if an osteochondral fragment can be salvaged. Chondroplasty and osteochondral autograft transfer are typically used to treat small (<2 cm) cartilage defects. Microfracture has not been shown to be superior to chondroplasty alone and has potential adverse effects, including cyst and intralesional osteophyte formation. Osteochondral allograft transfer and matrix-induced autologous chondrocyte implantation are often used for larger cartilage defects. Particulated juvenile allograft cartilage is another treatment option for cartilage lesions that has good to excellent short-term results but long-term outcomes are lacking.


Assuntos
Cartilagem da Orelha/lesões , Cartilagem da Orelha/cirurgia , Traumatismos do Joelho/patologia , Traumatismos do Joelho/cirurgia , Procedimentos Ortopédicos/métodos , Autoenxertos , Mau Alinhamento Ósseo/complicações , Condrócitos/transplante , Cartilagem da Orelha/patologia , Extremidades , Humanos , Traumatismos do Joelho/etiologia , Ligamentos , Tratamentos com Preservação do Órgão/métodos , Resultado do Tratamento
12.
J Card Surg ; 35(10): 2817-2820, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32740986

RESUMO

Anomalous origin of the left circumflex artery (LCA) arising from the right coronary sinus was observed in a 45-year-old man with aortic root aneurysm. Valve-sparing aortic root replacement (VSARR) was decided despite the subannular course of the LCA. A modified Tirone David procedure was performed with specific consideration for distribution of the proximal suture line due to the periaortic and subannular course of the LCA. Due to the risk of LCA injury, a coronary artery bypass grafting was performed using the left internal thoracic artery to secure the perfusion of the LCA. The challenging association of aortic root aneurysm and anomalous origin and course of the LCA was managed successfully during VSARR.


Assuntos
Aneurisma Aórtico/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Ponte de Artéria Coronária/métodos , Anomalias dos Vasos Coronários/cirurgia , Tratamentos com Preservação do Órgão/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Seio Aórtico/anormalidades , Resultado do Tratamento
13.
Pediatr Blood Cancer ; 67(9): e28526, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32618059

RESUMO

Testicular transposition (TT) before scrotal external radiotherapy (RT) is poorly reported in children with cancer, with only rare case reports published. TT surgical techniques, dosimetric parameters, and testicular functions are retrospectively reported in 12 children, median age 12.8 years, after scrotal RT for sarcomas. TT has low morbidity and allows a dramatic RT dose decrease in the healthy testicle. Endocrine functions seem preserved while more follow-up is needed to assess fertility. Though a rare situation, TT should be discussed in children and young adult cases when a scrotal high-dose RT is needed.


Assuntos
Preservação da Fertilidade/métodos , Tratamentos com Preservação do Órgão/métodos , Escroto/efeitos da radiação , Neoplasias Testiculares/radioterapia , Neoplasias Testiculares/cirurgia , Testículo/cirurgia , Adolescente , Criança , Pré-Escolar , Seguimentos , Humanos , Masculino , Prognóstico , Estudos Retrospectivos
14.
J Cancer Res Ther ; 16(3): 425-433, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32719246

RESUMO

Head-and-neck cancer (HNC) is in close proximity to several critical structures. Intensity-modulated radiation therapy (IMRT) has the potential of generating highly conformal and concave dose distributions around complex target and is ideally suited for HNC treatment. Conventionally, the focus of IMRT for HNC patients has been on prevention of radiation-induced parotid dysfunction. In the present article, we review the potential of IMRT to reduce the risk of posttreatment aspiration and dysphagia and spare submandibular gland. We also discuss the impact of IMRT on overall survival and quality of life (QoL) for HNC patients. Small retrospective and prospective studies show that reducing dose to adjoining organs at risks is feasible and decreases the risk of posttreatment dysphagia and aspiration without compromising local control. IMRT is associated with improved QoL in several important domains including swallowing, dry mouth, sticky saliva, social eating, and opening of the mouth; however, improvement in global QoL is inconsistent. Delivery of IMRT for HNC is associated with improved survival at nasopharyngeal subsite. Small studies demonstrate improved treatment outcomes with swallowing-sparing IMRT. These results now need validation within the prospective multicenter randomized controlled trial setting.


Assuntos
Carcinoma de Células Escamosas/radioterapia , Neoplasias de Cabeça e Pescoço/radioterapia , Tratamentos com Preservação do Órgão/métodos , Glândula Parótida/efeitos da radiação , Qualidade de Vida , Radioterapia de Intensidade Modulada/métodos , Carcinoma de Células Escamosas/patologia , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Dosagem Radioterapêutica , Resultado do Tratamento
15.
J Card Surg ; 35(8): 2059-2063, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32652648

RESUMO

Iatrogenic aortocoronary dissection is a rare but potentially fatal complication of coronary catheterizations. Although the incidence is comparatively low, dissection often leads to procedure failure with increased risk of myocardial infarction and death. Iatrogenic aortocoronary dissection is principally caused by disruption of intima at the ostia of the right or left coronary artery during interventional procedures and appears as luminal filling defects, the persistence of contrast or intimal tear outside the coronary lumen. We present a case of right coronary artery dissection leading to type-A aortic dissection suffered during diagnostic coronary catheterization. This required emergency supracoronary replacement of the ascending aorta with an aortic interposition tube graft and venous grafts to coronary arteries.


Assuntos
Aneurisma Dissecante/etiologia , Aneurisma Dissecante/cirurgia , Aorta/cirurgia , Valva Aórtica , Implante de Prótese Vascular/métodos , Cateterismo Cardíaco/efeitos adversos , Doença Iatrogênica , Tratamentos com Preservação do Órgão/métodos , Vasos Coronários , Feminino , Humanos , Pessoa de Meia-Idade
16.
Artigo em Inglês | MEDLINE | ID: mdl-32633904

RESUMO

Isolated endobronchial tumors of the left main bronchus are quite rare. They are treated by surgical resection, preferably using lung-sparing techniques, when possible. These procedures are technically challenging and are usually performed through a standard thoracotomy.  This video tutorial shows a left main bronchus sleeve resection with distal lobar carina reconstruction, performed through a uniportal thoracoscopic approach, for a typical carcinoid tumor of the distal left main bronchus.


Assuntos
Neoplasias Brônquicas , Tumor Carcinoide , Pneumonectomia/métodos , Cirurgia Torácica Vídeoassistida/métodos , Adulto , Brônquios/patologia , Brônquios/cirurgia , Neoplasias Brônquicas/patologia , Neoplasias Brônquicas/cirurgia , Tumor Carcinoide/patologia , Tumor Carcinoide/cirurgia , Humanos , Masculino , Tratamentos com Preservação do Órgão/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Resultado do Tratamento
17.
Sci Rep ; 10(1): 11368, 2020 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-32647361

RESUMO

Proton minibeams (MBs) comprised of parallel planar beamlets were evaluated for their ability to spare healthy brain compared to proton broad beams (BBs). Juvenile mice were given partial brain irradiation of 10 or 30 Gy integral dose using 100 MeV protons configured either as BBs or arrays of 0.3-mm planar MBs spaced 1.0 mm apart on center. Neurologic toxicity was evaluated during an 8-month surveillance: no overt constitutional or neurologic dysfunction was noted for any study animals. Less acute epilation was observed in MB than BB mice. Persistent chronic inflammation was noted along the entire BB path in BB mice whereas inflammation was confined to just within the MB peak regions in MB mice. The potential neurologic sparing, possibly via reduced volume of chronic inflammation, offers a compelling rationale for clinical advancement of this proton technique.


Assuntos
Neoplasias Encefálicas/radioterapia , Encéfalo/efeitos da radiação , Tratamentos com Preservação do Órgão/efeitos adversos , Terapia com Prótons/efeitos adversos , Lesões Experimentais por Radiação/diagnóstico , Animais , Técnicas de Observação do Comportamento , Comportamento Animal/efeitos da radiação , Encéfalo/patologia , Encéfalo/fisiopatologia , Cognição/fisiologia , Cognição/efeitos da radiação , Humanos , Masculino , Camundongos , Testes Neuropsicológicos , Tratamentos com Preservação do Órgão/instrumentação , Tratamentos com Preservação do Órgão/métodos , Projetos Piloto , Terapia com Prótons/instrumentação , Terapia com Prótons/métodos , Lesões Experimentais por Radiação/etiologia , Lesões Experimentais por Radiação/patologia , Lesões Experimentais por Radiação/fisiopatologia , Dosagem Radioterapêutica
18.
Dis Colon Rectum ; 63(8): 1053-1062, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692070

RESUMO

BACKGROUND: Patients with rectal cancer who achieve complete clinical response after neoadjuvant chemoradiation have been managed nonoperatively. Thirty percent of these patients may develop a local regrowth, and salvage resection with radical surgery is usually recommended. However, selected patients could be offered additional organ preservation by local excision. We hypothesized that patients with baseline T2 who underwent neoadjuvant therapy (for the specific purpose of achieving a complete clinical response) were more likely to harbor recurrent disease at an earlier stage and amenable to organ preservation strategies (local excision) when compared with T3/T4 (undergoing neoadjuvant chemoradiation for oncologic reasons). OBJECTIVE: The purpose of this study was to compare patients with local regrowth requiring salvage resection according to their baseline stage. DESIGN: This was a retrospective review of consecutive patients with nonmetastatic distal rectal cancer undergoing neoadjuvant chemoradiation. SETTINGS: The study included 2 independent tertiary centers with institutional watch-and-wait organ preservation programs. PATIENTS: Consecutive patients with distal rectal cancer (cT2-4N1-2M0) managed by watch and wait and local regrowth from 2 institutions were included. MAIN OUTCOMES MEASURES: Final pathologic features and surgical and oncologic outcomes were compared according to baseline staging. RESULTS: A total of 73 of 257 patients experienced local regrowth. cT2 presented similar to ypT, ypN, R0, and abdominal perineal resection rates (p > 0.05) at the time of salvage when compared with cT3 to cT4. Patients with cT2 at baseline were more likely to undergo an organ preservation procedure for salvage (56.2% vs 26.5%; p = 0.03). Overall and disease-free survival after salvage were similar between groups irrespective of the type of surgery for the regrowth. LIMITATIONS: Retrospective study, small sample size, and possible inaccurate baseline staging. CONCLUSIONS: Although patients with baseline cT2 rectal cancer had similar pathologic stage at the time of recurrence, these patients were more likely to continue an organ preservation pathway after local regrowth through transanal local excision when compared with cT3 to cT4. Despite differences in the use of radical salvage resection, there were no differences in oncologic outcomes. See Video Abstract at http://links.lww.com/DCR/B254. CIRUGÍA DE RESCATE CON PRESERVACIÓN DE ORGANO PARA PACIENTES CON RECIDIVA LOCAL LUEGO DE WATCH & WAIT: ¿SIGUE SIENDO POSIBLE?: Los pacientes con cáncer rectal que logran una respuesta clínica completa luego de la quimiorradiación neoadyuvante han sido tratados de forma no quirúrgica. El treinta por ciento de estos pacientes pueden desarrollar un nuevo crecimiento local y generalmente se recomienda la resección de rescate con cirugía radical. Sin embargo, en pacientes seleccionados se podría ofrecer la posibilidad de preservación de órgano mediante escisión local. Se formuló la hipótesis de que los pacientes con estadio clinico inicial T2 y sometidos a terapia neoadyuvante (con el propósito específico de lograr una respuesta clínica completa) tenían más probabilidades de presentar una recurrencia local en una etapa más temprana y suceptibles de estrategias de preservación de órgano (escisión local) en comparación con T3 / T4 (sometidos a nCRT por razones oncológicas).Comparar los pacientes con recidiva local que requirieron cirugia de rescate de acuerdo con su estadio inicial.Revisión retrospectiva de pacientes consecutivos con cáncer de recto distal no metastásico sometidos a quimiorradiación neoadyuvante.Dos centros terciarios independientes con programas institucionales de preservación de órgano - Watch & Wait.Pacientes consecutivos con cáncer rectal distal (cT2-4N1-2M0) manejados por Watch & Wait y recidiva local.Las características patológicas finales, los resultados quirúrgicos y oncológicos se compararon de acuerdo con la estadificación inicial.Un total de 73 de 257 pacientes presentaron recidiva local. cT2 presentaron similares ypT, ypN, R0 y tasas de resección abdominoperineal (p>0,05) en el momento del rescate en comparación con cT3-4.Los pacientes con cT2 de base tuvieron más probabilidades de someterse a un procedimiento de preservación de órgano durante el rescate (56,2% frente a 26,5%; p = 0,03). Supervivencia general y DFS después del rescate fueron similares entre los grupos, independientemente del tipo de cirugía para la recidiva.Estudio retrospectivo, tamaño de muestra pequeño, la posible estadificación basal inexacta.Aunque los pacientes con cáncer rectal cT2 de base presentaron estadio patologico similar en el momento de la recidiva, estos pacientes tuvieron más probabilidades de continuar una vía de preservación de órgano luego de una recidiva local a través de la escisión local transanal en comparación con cT3-4. A pesar de las diferencias en el uso de la resección radical de rescate, no hubo diferencias en los resultados oncológicos. Consulte Video Resumen en http://links.lww.com/DCR/B254.


Assuntos
Quimiorradioterapia/métodos , Recidiva Local de Neoplasia/cirurgia , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/radioterapia , Terapia de Salvação/métodos , Idoso , Estudos de Casos e Controles , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Preservação de Órgãos/métodos , Preservação de Órgãos/estatística & dados numéricos , Tratamentos com Preservação do Órgão/métodos , Protectomia/métodos , Protectomia/estatística & dados numéricos , Neoplasias Retais/patologia , Estudos Retrospectivos , Conduta Expectante/métodos
19.
Updates Surg ; 72(4): 1105-1113, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32504267

RESUMO

Infra-ampullary duodenal lesions are rare and surgical management is controversial. Reconstruction after resection is usually performed by end-to-end or end-to-side duodenojejunostomy. The goal was to analyze our experience, perioperative management, and results after side-to-side duodenojejunostomy. Therefore, we retrospectively evaluated short- and long-term results of surgical resections of third and fourth duodenal portions for several kinds of lesions and reconstruction through duodenojejunostomy performed in our facilities between January 2012 and December 2018. In total, 12 patients were selected for our study, six were male. The median age was 66.3 (IQR: 77.3-59.4). Lesion classification was as follows: 6 cases (50%) of duodenal adenocarcinoma, 4 cases (33.3%) of gastrointestinal stromal tumors (GISTs), and 2 cases (16.7%) of benign pathology. The most frequent clinical presentation was obstruction with vomiting. The surgical technique of choice was resection of third and fourth duodenal portions with a segment of proximal jejunum. Digestive continuity was restored through side-to-side duodenojejunostomy in 11 cases (91.6%). The median operation time was 182.5 min (IQR 237.5-136.3 min). Nine of the 12 patients (75%) did not receive intra- or postoperative blood transfusions. Six patients (50%) experienced complications during post-op. Four of them (33%) experienced major complications (Clavien-Dindo > IIIa) and three required re-op. The median follow-up was 58.3 (95% CI 15-101.5) months. Of the 11 patients with long-term follow-up, 10 have remained asymptomatic during follow-up. The average disease-free survival (DFS) was 43.1 months for adenocarcinoma, and 93 months for GIST. Based on the results of our series, although small, pancreas-sparing duodenectomy could be considered a feasible and safe technique with adequate oncological results. Side-to-side duodenojejunostomy appears to be a safe technique, is easy to perform, and has good functional outcomes. More studies with a larger number of patients are necessary to confirm these findings.


Assuntos
Duodeno/cirurgia , Jejunostomia/métodos , Tratamentos com Preservação do Órgão/métodos , Pâncreas/cirurgia , Adenocarcinoma/cirurgia , Idoso , Transfusão de Sangue/estatística & dados numéricos , Intervalo Livre de Doença , Duodenopatias/cirurgia , Neoplasias Duodenais/cirurgia , Estudos de Viabilidade , Feminino , Seguimentos , Tumores do Estroma Gastrointestinal/cirurgia , Humanos , Jejunostomia/mortalidade , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Tratamentos com Preservação do Órgão/mortalidade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento
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