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1.
Ann Surg Oncol ; 19(5): 1678-84, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22045465

RESUMO

BACKGROUND: Neoadjuvant chemoradiation (NCRT) has become the preferred treatment for patients with locally advanced esophageal cancer. Survival often is correlated to degree of pathologic response; however, outcomes in patients who are found to be pathologic nonresponders (pNR) remain uninvestigated. This study was designed to evaluate survival in pNR to NCRT compared with patients treated with primary esophagectomy (PE). METHODS: Using our comprehensive esophageal cancer database, we identified patients treated with NCRT and deemed pNR along with patients who proceeded to PE. Clinical and pathologic data were compared using Fisher's exact and χ(2), whereas Kaplan-Meier estimates were used for survival analysis. RESULTS: We identified 63 patients treated with NCRT and were found to have a pNR, and 81 patients who underwent PE. Disease-free (DFS) and overall survival (OS) were significantly decreased in the pNR group compared with those treated with PE (10 vs. 50 months (0-152), P < 0.001 and 13 vs. 50 months (0-152), P < 0.001, respectively). For patients with stage II disease, DFS and OS were similarly decreased in pathologic nonresponders (13 vs. 62 months (0-120), P < 0.001 and 31 vs. 62 months (0-120), P = 0.024, respectively). There were no differences in DFS or OS for patients with stage III disease (10 vs. 14 months (0-152), P = 0.29 and 10 vs. 19 months (0-152), P = 0.16, respectively). CONCLUSIONS: Pathologic nonresponders to NCRT for esophageal cancer receive no benefit in DFS or OS compared with patients treated with PE. For patients with stage II disease, DFS and OS are, in fact, significantly decreased in the pNR.


Assuntos
Adenocarcinoma/mortalidade , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/terapia , Quimiorradioterapia , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/terapia , Esofagectomia , Adenocarcinoma/patologia , Adenocarcinoma/secundário , Adenocarcinoma/terapia , Idoso , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/secundário , Neoplasias Esofágicas/patologia , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Análise de Sobrevida , Resultado do Tratamento
2.
Ann Surg Oncol ; 18(3): 824-31, 2011 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-20865331

RESUMO

BACKGROUND: Incidences of esophageal cancer and obesity are both rising in the United States. The aim of this study was to determine the influence of elevated body mass index on outcomes after esophagectomy for cancer. METHODS: Overall and disease-free survivals in obese (BMI ≥ 30), overweight (BMI 25-29), and normal-weight (BMI 20-24) patients undergoing esophagectomy constituted the study end points. Survivals were calculated by the Kaplan-Meier method, and differences were analyzed by log rank method. RESULTS: The study included 166 obese, 176 overweight, and 148 normal-weight patients. These three groups were similar in terms of demographics and comorbidities, with the exception of younger age (62.5 vs. 66.2 vs. 65.3 years, P = 0.002), and higher incidence of diabetes (23.5 vs. 11.4 vs. 10.1%, P = 0.001) and hiatal hernia (28.3 vs. 14.8 vs. 20.3%, P = 0.01) in obese patients. Rates of adenocarcinoma histology were higher in obese patients (90.8 vs. 90.9 vs. 82.5%, P = 0.03). Despite similar preoperative stage, obese patients were less likely to receive neoadjuvant treatment (47.6 vs. 54.5 vs. 66.2%, P = 0.004). Response to neoadjuvant treatment, type of surgery performed, extent of lymphadenectomy, rate of R0 resections, perioperative complications, and administration of adjuvant chemotherapy were not influenced by BMI. At a median follow-up of 25 months, 5-year overall and disease-free survivals were longer in obese patients (respectively, 48, 41, 34%, P = 0.01 and 48, 44, 34%, P = 0.01). CONCLUSIONS: In our experience, an elevated BMI did not reduce overall and disease-free survivals after esophagectomy for cancer.


Assuntos
Adenocarcinoma/mortalidade , Índice de Massa Corporal , Carcinoma de Células Escamosas/mortalidade , Neoplasias Esofágicas/mortalidade , Esofagectomia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/cirurgia , Terapia Combinada , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/cirurgia , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Obesidade , Sobrepeso , Assistência Perioperatória , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
3.
Obes Surg ; 15(2): 238-42, 2005 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-15802067

RESUMO

BACKGROUND: Obese patients are at increased risk for biliary disease. The prevalence and type of gallbladder pathology in morbidly obese patients was evaluated, and compared with a non-obese control group. METHODS: A consecutive series of obese patients (n=478) who had undergone bariatric surgery with concurrent routine cholecystectomy and a consecutive group of organ donors (n=481) were compared. Gallbladder pathology was defined as: cholelithiasis, cholecystitis, cholesterolosis, or normal pathology. RESULTS: Mean age of obese patients and of donors was 42 +/- 9 and 43 +/- 17 years respectively and mean BMI was 52 +/- 10 and 27 +/- 7 kg/m2 respectively, P<0.05. There were more females in the obesity group (88% vs 47%, P<0.0001). 31% of obese patients and 7% of controls had a previous cholecystectomy (P<0.0001). 21% of the obese and 72% of the controls had normal gallbladder pathology (P<0.0001). Overall, obese patients had a higher incidence of cholelithiasis (25% vs 5%, P<0.0001), cholecystitis (50% vs 17%, P<0.0001), and cholesterolosis (38% vs 6%, P<0.0001) compared with controls. Obese patients with BMI <50 were more likely than those with BMI > or =50 to have normal gallbladder pathology (27% vs 14%, P<0.001). Female patients were more likely to have undergone previous cholecystectomy than males in both the obese group (34% vs 11%, P<0.001) and the control group (12% vs 2%, P<0.0001). Normal pathology was more common in male patients (80% vs 63%, P<0.0001) and patients <50 years (76% vs 66%, P<0.05) in the control group. CONCLUSIONS: Obese patients have an increased incidence of benign gallbladder disease than a group of controls, and the relative risk appears to be positively correlated with the level of increase in the BMI. Obesity appears to change the effect of age and gender on gallbladder pathology.


Assuntos
Doenças da Vesícula Biliar/epidemiologia , Doenças da Vesícula Biliar/patologia , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Idoso , Biópsia por Agulha , Índice de Massa Corporal , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Colecistectomia/métodos , Comorbidade , Feminino , Seguimentos , Gastroplastia/métodos , Humanos , Imuno-Histoquímica , Incidência , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Probabilidade , Valores de Referência , Medição de Risco , Índice de Gravidade de Doença , Distribuição por Sexo , Resultado do Tratamento
4.
Am J Surg ; 188(6): 736-40, 2004 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-15619492

RESUMO

BACKGROUND: Chronic inguinal neuralgia is one of the most significant complications following inguinal hernia repair. Routine ilioinguinal nerve excision has been proposed as a means to avoid this complication. The purpose of this report is to evaluate the long-term outcomes of neuralgia and paresthesia following routine ilioinguinal nerve excision compared to nerve preservation. METHODS: Retrospective chart review identified 90 patients who underwent Lichtenstein inguinal hernia repairs with either routine nerve excision (n = 66) or nerve preservation (n = 24). All patients were contacted and data was collected on incidence and duration of postoperative neuralgia and paresthesia. Comparison was made by chi(2) analysis. RESULTS: The patients with routine neurectomy were similar to the group without neurectomy based on gender (male/female 51/15 vs. 19/5) and mean age (68 +/- 14 vs. 58 +/- 18 years). In the early postoperative period (6 months), the incidence of neuralgia was significantly lower in the neurectomy group versus the nerve preservation group (3% vs. 26%, P <0.001). The incidence of paresthesia in the distribution of the ilioinguinal nerve was not significantly higher in the neurectomy group (18% vs. 4%, P = 0.10). At 1 year postoperatively, the neurectomy patients continued to have a significantly lower incidence of neuralgia (3% vs. 25%, P = 0.003). The incidence of paresthesia was again not significantly higher in the neurectomy group (13% vs. 5%, P = 0.32). In patients with postoperative neuralgia, mean severity scores on a visual analog scale (0-10) were similar in neurectomy and nerve preservation patients at all end points in time (2.0 +/- 0.0 to 2.5 +/- 0.7 vs. 1.0 +/- 0.0 to 2.2 +/- 1.5). In patients with postoperative paresthesia, mean severity scores on a visual analog scale (0-10) were similar in the neurectomy and nerve preservation patients at 1 year (2.5 +/- 2.2 vs. 4.0 +/- 0.0) and 3 years (3.5 +/- 2.9 vs. 4.0 +/- 0.0). CONCLUSIONS: Routine ilioinguinal neurectomy is associated with a significantly lower incidence of postoperative neuralgia compared to routine nerve preservation with similar severity scores in each group. There is a trend towards increased incidence of subjective paresthesia in patients undergoing routine neurectomy at 1 month, but there is no significant increase at any other end point in time. When performing Lichtenstein inguinal hernia repair, routine ilioinguinal neurectomy is a reasonable option.


Assuntos
Hérnia Inguinal/cirurgia , Canal Inguinal/inervação , Plexo Lombossacral/cirurgia , Dor Pós-Operatória/prevenção & controle , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Seguimentos , Hérnia Inguinal/diagnóstico , Humanos , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Satisfação do Paciente , Probabilidade , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
5.
Curr Treat Options Gastroenterol ; 9(5): 371-6, 2006 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16942661

RESUMO

Adenomatous lesions of the ampulla of Vater are relatively rare neoplasms that raise many questions regarding standard management. Adenocarcinoma often will be found in ampullary lesions and should be treated by pancreaticoduodenectomy (PD). Benign-appearing adenomas may be treated by PD, transduodenal ampullectomy (AMP), or endoscopic ampullectomy (EA). AMP and EA have decreased morbidity and mortality compared with PD but are limited by concerns for appropriate resection margins, high recurrence rates, and the need for surveillance endoscopy or additional procedures. Preoperative endoscopic biopsies should be obtained to identify carcinoma, but they have high false-negative rates and cannot be relied upon to rule out malignancy. Intraoperative frozen section evaluation should be requested routinely during AMP, with conversion to PD if carcinoma is demonstrated. The gold standard management of benign adenomas has not been clarified, but the goal for all treatment modalities is complete resection. Patients with familial adenomatous polyposis may be exceptions to this, and routine surveillance endoscopy and biopsy with selective resection have been advocated by some as an alternative to complete resection. Adjuvant chemoradiation has a very limited role in the treatment of ampullary carcinoma and ideally should be offered in the setting of a clinical trial. Metastatic and locally advanced, unresectable lesions may be palliated by surgical or endoscopic bypass, as well as by celiac plexus blockade.

6.
Proc (Bayl Univ Med Cent) ; 18(3): 211-3, 2005 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-16200174

RESUMO

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been considered the nonsurgical gold standard for the diagnosis and treatment of choledocholithiasis (CDL). Complications include a 0.1% to 1.3% mortality rate and a 5% to 19% morbidity rate, including a reported 1.8% to 6.7% incidence of postprocedure pancreatitis. Twenty-seven percent to 67% of ERCPs done for suspected choledocholithiasis ultimately have negative results. Endoscopic ultrasound (EUS) has been proposed as an alternate means of diagnosing choledocholithiasis that may eliminate the need for ERCP and its associated morbidities in certain patients. METHODS: Retrospective chart review identified 30 patients who underwent EUS with or without ERCP for suspected choledocholithiasis. Reports of all procedures performed were obtained and data were collected on all biliary abnormalities identified on both EUS and ERCP. RESULTS: Pancreaticobiliary abnormalities were identified in 27 of 30 patients (90%) at EUS. Most common diagnoses included CDL (n = 9, 30%), biliary sludge (n = 11, 37%), pancreatitis (n = 8, 27%), and cholelithiasis (n = 7, 23%). Subsequent ERCP was performed in 14 patients (47%). Indications included a diagnosis of CDL by EUS (n = 9) and abnormal liver function tests (n = 5). CDL was identified in 5 of 14 patients (36%), and microlithiasis/biliary sludge was identified in an additional 5 patients (36%). In 4 patients, CDL was identified by EUS but not by ERCP. ERCP did not identify any new cases of CDL after EUS: of 21 patients without evidence of CDL on EUS, none were subsequently shown to have CDL or to develop any complications related to common duct stones. CONCLUSIONS: EUS is an effective method of diagnosing CDL. It demonstrates both a high sensitivity and specificity for identifying common bile duct stones. Its use as a screening modality in patients suspected of having CDL may allow more selective use of ERCP.

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