RESUMO
BACKGROUND: Anal adenocarcinoma bears a treatment strategy unique to other anal cancers. OBJECTIVE: This study aimed to describe oncologic outcomes of total neoadjuvant therapy followed by watch-and-wait approach for anal adenocarcinoma. DESIGN: Retrospective analysis. SETTINGS: This study was conducted at a comprehensive cancer center. PATIENTS: Patients with anal adenocarcinoma treated between 2004 and 2019 were selected. INTERVENTIONS: Fifty-four patients received neoadjuvant therapy and were divided into 2 groups according to their treatment strategy: total neoadjuvant therapy versus single neoadjuvant modality therapy. MAIN OUTCOME MEASURES: Organ preservation, tumor regrowth, local failure, distant metastasis rates, recurrence-free survival, and overall survival. RESULTS: This study included 70 patients with anal adenocarcinoma. Fifty-four patients (77%) received neoadjuvant therapy, of whom 30 (42%) received total neoadjuvant therapy and 24 (34%) received single neoadjuvant modality. Twenty-three (33%) patients achieved complete clinical response and were managed by watch-and-wait approach. The proportion of patients able to continue to watch-and-wait approach was higher after receiving total neoadjuvant therapy (60%) compared with single neoadjuvant modality therapy (20%; p = 0.004). A tumor regrowth rate of 22% was observed in the total neoadjuvant therapy group. The 5-year overall survival rate was 70% (95% CI, 59%-83%), including 61% (95% CI, 42%-88%) for the total neoadjuvant therapy and 65% (95% CI, 48%-88%) for the single neoadjuvant modality groups. Colostomy was avoided in 50% of patients who received total neoadjuvant therapy and 83% of watch-and-wait patients. Five-year recurrence-free survival rates of 55% (95% CI, 39%-79%) and 30% (95% CI, 15%-58%) were observed in the total neoadjuvant therapy and single neoadjuvant modality groups. LIMITATIONS: Retrospective nature. CONCLUSIONS: This is the first report in the literature describing the safety and feasibility of nonoperative management for anal adenocarcinoma. Anal adenocarcinoma treated with total neoadjuvant therapy and nonoperative management achieve regrowth rates comparable to those observed in rectal cancer, with oncologic outcomes similar to those of traditional treatment strategies. See Video Abstract . ADENOCARCINOMA ANAL TRATADO EN LA ERA DE LA TERAPIA NEOADYUVANTE TOTAL Y EL TRATAMIENTO NO QUIRRGICO: ANTECEDENTES:El adenocarcinoma anal conlleva una estrategia de tratamiento único para otros cánceres anales.OBJETIVO:Describir los resultados oncológicos de la terapia neoadyuvante total seguida de observar y esperar en adenocarcinoma anal.DISEÑO:Análisis retrospectivo.AJUSTE:Este estudio se llevó a cabo en un centro oncológico integral.PACIENTES:Se seleccionaron pacientes con adenocarcinoma anal tratados entre 2004-2019.INTERVENCIONES:Cincuenta y cuatro pacientes recibieron terapia neoadyuvante y se dividieron en dos grupos según su estrategia de tratamiento: terapia neoadyuvante total versus terapia de modalidad neoadyuvante única.PRINCIPALES MEDIDAS DE RESULTADO:Preservación de órganos, recurrencia tumoral, falla local, tasas de metástasis a distancia, libre de recurrencia y supervivencia general.RESULTADOS:El estudio incluyó a 70 pacientes con adenocarcinoma anal. Cincuenta y cuatro pacientes (77%) recibieron terapia neoadyuvante, de los cuales 30 (42%) recibieron terapia neoadyuvante total y 24 (34%) recibieron modalidad neoadyuvante única. Veintitrés (33%) pacientes presentaron una respuesta clínica completa y fueron tratados con vigilancia y espera. La proporción de pacientes capaces de continuar en observar y esperar fue mayor después de recibir terapia neoadyuvante total (60%) en comparación con la terapia de modalidad neoadyuvante única (20%) ( p = 0,004). Se observó una tasa de recurrencia tumoral del 22% en el grupo de terapia neoadyuvante total. La tasa de supervivencia general a 5 años fue del 70% (IC95% 59%-83 %), incluido el 61% (IC95% 42%-88%) para la terapia neoadyuvante total y el 65% (IC95% 48%-88%) para grupos de modalidad neoadyuvante única. Se evitó la colostomía en el 50% de los pacientes que recibieron terapia neoadyuvante total y el 83% de los pacientes en observar y esperar. Se observaron tasas de supervivencia libre de recurrencia a cinco años del 55% (IC95% 39%-79%) y del 30% (IC95% 15%-58%) en los grupos de terapia neoadyuvante total y modalidad neoadyuvante única, respectivamente.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:Este es el primer informe en la literatura que describe la seguridad y viabilidad del tratamiento no quirúrgico del adenocarcinoma anal. El adenocarcinoma anal tratado con terapia neoadyuvante total y manejo no quirúrgico logra tasas de recurrencia comparables a las observadas en el cáncer de recto, con resultados oncológicos similares a las estrategias de tratamientos tradicionales. (Traducción-Dr. Fidel Ruiz Healy ).
Assuntos
Adenocarcinoma , Neoplasias do Ânus , Neoplasias Retais , Humanos , Estudos Retrospectivos , Terapia Neoadjuvante , Conduta Expectante , Neoplasias Retais/patologia , Neoplasias do Ânus/terapia , Neoplasias do Ânus/patologia , Quimiorradioterapia , Adenocarcinoma/patologia , Recidiva Local de Neoplasia/terapia , Recidiva Local de Neoplasia/tratamento farmacológico , Resultado do Tratamento , Estadiamento de NeoplasiasRESUMO
BACKGROUND: Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population. METHODS: An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed. RESULTS: Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs ( P â=â0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs ( P â=â0.02). CONCLUSIONS: Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations.
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Traumatismo Cerebrovascular , Automutilação , Ferimentos por Arma de Fogo , Ferimentos não Penetrantes , Traumatismo Cerebrovascular/epidemiologia , Humanos , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos por Arma de Fogo/diagnóstico por imagem , Ferimentos por Arma de Fogo/epidemiologiaRESUMO
BACKGROUND: The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe. METHODS: We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019. RESULTS: The adverse event rate of TORe was 17.1â% (nâ=â22), with a 13.3â% (nâ=â17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8â%) responded to endoscopic balloon dilation and 7 (41.2â%) required stent placement. CONCLUSION: As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe.
Assuntos
Derivação Gástrica , Obesidade Mórbida , Humanos , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Técnicas de Sutura , Suturas , Resultado do Tratamento , Aumento de PesoRESUMO
The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.
Assuntos
Justiça Social , Útero , Beneficência , Ética Médica , Feminino , Humanos , Útero/transplanteRESUMO
Harold Gillies, a plastic surgeon who created the discipline of plastic surgery and trained hundreds of young surgeons, was foremost an artist. In a short historical perspective, we illustrate this facet of the Gillies' life through a friendship with the British ecologist William Sladen and a painting that Gillies drew during their encounters.
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Traumatismos Faciais/cirurgia , Pinturas/história , Cirurgia Plástica/história , Inglaterra , História do Século XX , HumanosRESUMO
PURPOSE: Self-inflicted facial gunshots (SIGSWs) typically result in a spectrum of severe injuries to facial structures, including the orbit and globe. Roughly three-quarters of those who arrive to the hospital will survive their injuries, and recidivism is typically low. Therefore, effective management is paramount to preserve vision, and long-term quality of life. The objective of this study is to characterize the common injuries to the orbit, globe, and periocular structures following SIGSWs, their management, and their eventual visual and reconstructive outcomes. METHODS: Retrospective review of trauma registry records at a Level 1 trauma center for patients who presented alive following SIGSWs involving the globe and/or orbit from 2007 to 2016. RESULTS: Of the 47 patients who presented with SIGSWs to the orbit, 33 (70%) were discharged alive from the hospital. Management strategies for these patients fell into 3 groups, based on the involved structures: i) Open globe injuries (Type I: n = 12, 34%) ii) Orbital fractures with preserved globe and optic nerve (Type II: n = 15, 43%), and iii) Optic nerve injuries with preserved globe (Type III: n = 8, 23%). Compared with Type II and III injuries, patients who had Type I injuries were more likely to die prior to hospital discharge (46% vs. 20% vs. 12%, p = 0.04), undergo ophthalmologic intervention (73% vs. 6% vs. 11%, p = 0.01), and more surgery (6 vs. 3 vs. 0.5 mean surgeries, p < 0.001). Type II injuries most frequently underwent debridement and reconstruction of the bony orbit. Type III and Type I injuries were associated with worse initial and final visual acuity, with the majority (100% and 75%, respectively) having No Light Perception (NLP) on initial exam, and no visual recovery during the follow-up period (median follow up= 25 months). CONCLUSIONS: Management and visual outcomes of orbital injuries from SIGSWs is determined by whether the globe and optic nerve are preserved. Open globe injury by itself is associated with higher mortality and significant permanent vision loss.
Assuntos
Traumatismos Oculares , Fraturas Orbitárias , Traumatismos Oculares/diagnóstico , Traumatismos Oculares/epidemiologia , Traumatismos Oculares/etiologia , Humanos , Fraturas Orbitárias/diagnóstico , Fraturas Orbitárias/etiologia , Fraturas Orbitárias/cirurgia , Qualidade de Vida , Estudos Retrospectivos , Acuidade VisualRESUMO
BACKGROUND: Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population. METHODS: The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population. RESULTS: In total, 4608 consecutive patients were included. Infections were found in 4.8% (nâ=â219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, Pâ<â0.001), assault-related injury (OR 1.61, Pâ=â0.003), positive toxicology screen (OR 1.56, Pâ=â0.004), and male gender (OR 1.53, Pâ=â0.037) were significantly associated with a BPI diagnosis. CONCLUSION: Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).
Assuntos
Patógenos Transmitidos pelo Sangue , Traumatismos Maxilofaciais/epidemiologia , Adulto , Feminino , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Hepatite B/complicações , Hepatite B/epidemiologia , Hepatite C/complicações , Hepatite C/epidemiologia , Humanos , Incidência , Masculino , Traumatismos Maxilofaciais/complicações , Prevalência , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: The purpose of this study was to characterize differences in facial fracture injury patterns among pediatric patients at highest risk of abusive head trauma/nonaccidental trauma (ageâ≤â5 years). METHODS: Using the National Trauma Databank from 2007 to 2015, patients (ageâ≤â5 years) suffering facial fractures were included. Demographics and injury characteristics were compared between those sustaining accidental versus nonaccidental trauma (NAT). RESULTS: Over 9 years 9741 patients were included with 193 patients (2.0%) suffering NAT. Nonaccidental trauma patients were younger (median [interquartile range]; 0 [0, 2] versus 3 [1, 4], Pâ<â0.001), and more frequently were insured by Medicaid (76.7% versus 41.9%, Pâ<â0.001). NAT patients were more likely to sustain mandible fractures (38.9% versus 21.1%, Pâ<â0.001), but less likely to sustain maxilla (9.8% versus 18.3%, Pâ=â0.003), or orbital fractures (31.1% versus 53.4%, Pâ<â0.001). Nonaccidental trauma patients had fewer instances of multiple facial fracture sites (8.9% versus 22.6%, Pâ<â0.001). Among those sustaining mandible fractures, NAT patients were more likely to sustain condylar fractures (75.8% versus 48.4%, Pâ<â0.001), but less likely to sustain subcondylar fractures (0% versus 13.2%, Pâ=â0.002), or angle fractures (1.6 versus 8.7%, Pâ=â0.048). CONCLUSIONS: Differences exist in facial fracture patterns in accidental versus nonaccidental trauma within the pediatric population at highest risk for abusive head trauma. Specifically, NAT is associated with fractures of the mandibular condyle and involve fewer facial fracture sites. In the appropriate context, presence of these fractures/patterns should increase suspicion for NAT.
Assuntos
Fraturas Cranianas/epidemiologia , Acidentes , Maus-Tratos Infantis , Pré-Escolar , Traumatismos Craniocerebrais , Bases de Dados Factuais , Traumatismos Faciais , Fraturas Múltiplas , Humanos , Lactente , Recém-Nascido , Estudos RetrospectivosRESUMO
Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post-surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African-American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence.
Assuntos
Hidradenite Supurativa/complicações , Hidradenite Supurativa/cirurgia , Transplante de Pele/métodos , Cicatrização/fisiologia , Adulto , Feminino , Humanos , Masculino , Maryland , Recidiva , Estudos Retrospectivos , Adulto JovemRESUMO
Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT-PAN). We describe our 8-year experience performing LRT-PAN. A retrospective chart review of all patients who had undergone LRT-PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty-eight patients underwent LRT-PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety-day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft-related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter-than-expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.
Assuntos
Abdominoplastia/métodos , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Doadores Vivos/provisão & distribuição , Obesidade/cirurgia , Complicações Pós-Operatórias , Cuidados Pré-Operatórios , Adulto , Idoso , Índice de Massa Corporal , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Falência Renal Crônica/complicações , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: Presentation of pediatric facial fractures varies widely and many injuries are encountered infrequently by most practitioners. This study summarizes injury patterns in a large cohort of facial fractures and their subsequent surgical management. METHODS: Demographic and clinical characteristics of patients 18 years of age or younger admitted between 2009 and 2015 to trauma centers participating in the National Trauma Data Bank were examined. Craniofacial fractures and reconstructive procedures performed at index admission were selected based on ICD-9 and AIS codes. A multivariable analysis was used to determine independent determinants of surgical repair. RESULTS: Out of 60,094 pediatric patients evaluated in the US emergency departments, 48,821 patients were admitted and underwent open treatment (nâ=â8364; 17.1%) or closed treatment (nâ=â4244; 8.7%) of facial fractures. Falls were the most common mechanism of injury in infants and toddlers (<2-year-old, 44.4%, Pâ<0.001), while motor vehicle collisions (32.9%, Pâ<0.001) and assault (22.1%, Pâ<0.001) were most commonly seen in adolescents (12-18-year-old). The frequency and odds of repair of facial fractures increased with advancing age, more so with open than closed treatment in adolescents (73.0%) as compared to infants and toddlers (50.3%). Children who sustained mandible fractures are the most likely to require surgical treatment at index-admission (odds ratioâ=â13.9, 95% confidence interval 13.1-14.8, Pâ<0.001). CONCLUSIONS: Population-based data shows that pediatric fracture patterns and associated early repair vary significantly with age. Patient demographics and hospital characteristics are significant determinants of surgical treatment that should be related to clinical outcomes in future studies.
Assuntos
Fraturas Cranianas , Acidentes por Quedas , Acidentes de Trânsito , Adolescente , Distribuição por Idade , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Hospitalização , Humanos , Lactente , Recém-Nascido , Masculino , Procedimentos de Cirurgia Plástica , Fraturas Cranianas/cirurgia , Centros de TraumatologiaRESUMO
BACKGROUND: Contemporary description of facial fracture patterns and factors associated with early operative intervention at trauma centers is lacking. The purpose of this study was to characterize injuries and initial treatment patterns of patients suffering from facial fractures. METHODS: Using the National Trauma Databank from 2007 to 2015, patients suffering from facial fractures were included. Demographics, injury characteristics, and outcomes including operative interventions were assessed. RESULTS: Over 9 years, 626,270 patients were included: 74.5% were male, 39.0% suffered traumatic brain injury (TBI), and 23.3% severe noncraniofacial injuries (chest, abdomen, and/or extremity Abbreviated Injury Score ≥3). A total of 537,594 (85.8%) patients were admitted and 184,206 (34.3%) underwent operations for their facial injuries during the index hospitalization. The frequency and patterns of fractures varied by age, sex, race, and mechanism of injury. Operative intervention rates were highest for mandible (63.2%) and lowest for orbit fractures (1.0%). Multiple regression revealed that multiple factors were independently associated with the odds of early fracture repair including: female versus male (odds ratio [95% confidence interval]: 0.96 [0.94-0.98]), age >65 versus <18 years (0.62 [0.59-0.64]), non-white race (0.95 [0.94-0.97]), uninsured versus Medicaid (0.88 [0.86-0.90]), hospital bed size (>600 vs ≤200 beds, 1.67 [1.61-1.73]), TBI (0.70 [0.69-0.71]), and C-spine injury (0.93 [0.90-0.96]). CONCLUSIONS: Facial fractures are common among many demographic cohorts, and multiple patient and injury-specific factors influenced fracture patterns and management. Early operative intervention was highest for mandible fractures and lowest for orbit fractures. Multiple factors including age, sex, insurance status, hospital characteristics, and race/ethnicity were independently associated with early operative intervention, highlighting disparities in care.
Assuntos
Fraturas Cranianas , Adolescente , Adulto , Idoso , Bases de Dados Factuais , Traumatismos Faciais/epidemiologia , Traumatismos Faciais/terapia , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Fraturas Cranianas/epidemiologia , Fraturas Cranianas/terapia , Adulto JovemRESUMO
Necrotizing fasciitis of the foot is a relatively rare diagnosis and has traditionally been treated with distal amputation. A 30-year-old diabetic man with Charcot-Marie-Tooth muscular atrophy developed necrotizing fasciitis of the dorsal foot and underwent surgical debridement resulting in a significant wound with exposed tendons. Serial debridements were performed, eventually followed by a staged free flap reconstruction using an anterolateral thigh fasciocutaneous flap. After allowing time for flap healing, subsequent staged equinovarus reconstruction was also performed successfully. There were no flap or postoperative complications, and the patient is progressing as expected. Flap refinement procedures have been used to enhance cosmetic and functional outcomes. This report not only showcases the success of a procedure high on the reconstructive ladder in a patient at high risk for complications but also highlights an approach in which functional recovery is also optimized successfully in a planned staged multidisciplinary manner.
Assuntos
Doença de Charcot-Marie-Tooth , Fasciite Necrosante , Retalhos de Tecido Biológico , Masculino , Humanos , Adulto , Desbridamento , Fasciite Necrosante/etiologia , Fasciite Necrosante/cirurgia , PéRESUMO
BACKGROUND: Bariatric surgery has been postulated to impact liver function resulting in favorable effects on nonalcoholic fatty liver disease (NAFLD). We aimed to analyze the long-term impact of bariatric surgery on noninvasive scores predicting the progression of liver fibrosis in a bariatric population. METHODS: We retrospectively reviewed the records of patients without pre-existing liver disease who underwent sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) at our center between 2010 and 2018. Four predictive scores for liver fibrosis (AST/ALT, APRI, Fib-4, and BARD) were calculated preoperatively, 6 months post-operatively, and annually up to 5 years. Correlations were analyzed with Pearson R. Subgroup and sensitivity analyses were performed to identify populations at increased risk. RESULTS: A total of 2769 patients were included. The mean age was 40 years, and the majority was females (88.5%) and of Hispanic ethnicity (59.2%). There was a steady post-operative increase in the percentage of patients at increased risk of progression of liver fibrosis. The Fib-4 score showed the largest increase in the population at risk for liver fibrosis (11.3% preoperatively to 28.9% at 5 years). Patients with diabetes and those who underwent a sleeve gastrectomy continued to display a higher risk for liver fibrosis than did patients without diabetes and those who underwent RYGB, respectively. CONCLUSION: There was an overall trend to increased liver fibrosis scores over the 5-year post-operative follow-up, but this increase remained lower than that reported in previous literature. Bariatric surgery offers NAFLD risk reduction in a high-risk population.
Assuntos
Cirurgia Bariátrica , Diabetes Mellitus , Derivação Gástrica , Hepatopatia Gordurosa não Alcoólica , Obesidade Mórbida , Feminino , Humanos , Adulto , Hepatopatia Gordurosa não Alcoólica/cirurgia , Estudos Retrospectivos , Obesidade Mórbida/cirurgia , Redução de Peso , Cirurgia Bariátrica/métodos , Derivação Gástrica/métodos , Cirrose Hepática/cirurgia , Gastrectomia/métodos , Diabetes Mellitus/cirurgiaRESUMO
PURPOSE: Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to characterize common patterns in insurance coverage, we report coverage criteria for adolescents relative to adults. MATERIALS AND METHODS: We surveyed medical policies of the 50 highest market share health insurance providers in the USA. Private insurer coverage criteria included age, Tanner staging, skeletal maturity, body mass index, procedures covered, medical weight management requirements, co-morbidities, and multidisciplinary team criteria. These were then compared to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. RESULTS: Two thirds (n = 33, 66%) of companies provided inclusion criteria for adolescents. All policies covered RYGB (n = 33), most covered sleeve gastrectomy (n = 32, 97.0%). Obstructive sleep apnea (OSA) (n = 32, 97%), hypertension (HTN) (n = 27, 81.8%), and gastroesophageal reflux disease (GERD) (n = 11, 33.3%) were the three most commonly cited co-morbidities used as inclusion criteria. Tanner staging or skeletal maturity were most commonly used (n = 10, 30.3%). Similarly, twenty (60.6%) insurers required medical weight management programs. Multi-disciplinary teams were required by 81.8% of adolescent policies (n = 27) as described by the ASMBS. Seventeen (51.5%) policies defined providers for these teams, and 10 (30.3%) provided other defined criteria. CONCLUSION: Contrary to ASMBS guidelines, companies commonly require Tanner staging and/or skeletal maturity criteria as well as participation in medical weight management programs. Also, multi-disciplinary team are frequently required but not well defined.
Assuntos
Cirurgia Bariátrica , Obesidade Mórbida , Adolescente , Adulto , Criança , Estudos Transversais , Humanos , Cobertura do Seguro , Obesidade , Obesidade Mórbida/cirurgiaRESUMO
BACKGROUND: The purpose of this study was to characterize demographics, injury patterns, and initial management trends of facial fracture patients who were subject to interfacility transfer. METHODS: Using the National Trauma Data Bank from 2007 to 2015, facial fracture patients arriving by interfacility transfer were included in the study. RESULTS: Over 9 years, 171,618 patients were included, with 37.5 percent having an isolated facial injury. Isolated facial injury patients tended to be younger, less frequently white, more frequently assaulted, and more frequently underwent facial fracture operative repair during the index admission (all, p < 0.001). From 2007 to 2015, insurance coverage increased from 54.6 to 79.0 percent (R2 = 0.90, p < 0.001). In addition, there was a 45 percent proportional increase in patients 50 to 89 years of age compared to a 20 percent decrease in patients 0 to 39 years of age (both, R2 = 0.99, p < 0.001). The proportion of transfer patients with isolated facial injury increased over the study period (32.0 to 39.4 percent, R2 = 0.90, p < 0.001); however, there was a decline in operative intervention (29.5 to 22.1 percent, R2 = 0.94, p < 0.001) and a 151 percent increase in the proportion discharged from the emergency department upon transfer arrival (R2 = 0.99, p < 0.001). CONCLUSIONS: Facial fracture patients subject to interfacility transfer comprise a wide array of demographics and injury patterns, with most having concomitant injuries and only a minority undergoing immediate operative intervention. Over time, this demographic has become older, sustained more isolated facial injury, and undergone fewer immediate operative interventions and is more frequently insured and more frequently discharged from the emergency department upon transfer arrival, reflecting increasing rates of secondary overtriage.
Assuntos
Traumatismos Faciais , Fraturas Cranianas , Adolescente , Adulto , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Traumatismos Faciais/cirurgia , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Transferência de Pacientes , Estudos Retrospectivos , Fraturas Cranianas/cirurgia , Centros de Traumatologia , Adulto JovemRESUMO
BACKGROUND: Body contouring in the postbariatric surgery patient improves quality of life and daily function. OBJECTIVES: To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers. METHODS: We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls. RESULTS: One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046). CONCLUSION: In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.
Assuntos
Abdominoplastia , Cirurgia Bariátrica , Obesidade Mórbida , Complicações Pós-Operatórias/epidemiologia , Abdominoplastia/efeitos adversos , Acreditação , Humanos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Pontuação de Propensão , Melhoria de Qualidade , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis. METHODS: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses. RESULTS: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases. CONCLUSIONS: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Assuntos
Tratamento Conservador/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Redução Aberta/estatística & dados numéricos , Fraturas Orbitárias/terapia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/efeitos adversos , Feminino , Fixação Interna de Fraturas/efeitos adversos , Hematoma/diagnóstico , Hematoma/epidemiologia , Hematoma/etiologia , Hematoma/prevenção & controle , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Redução Aberta/efeitos adversos , Traumatismos do Nervo Óptico/diagnóstico , Traumatismos do Nervo Óptico/epidemiologia , Traumatismos do Nervo Óptico/etiologia , Traumatismos do Nervo Óptico/prevenção & controle , Órbita/irrigação sanguínea , Órbita/diagnóstico por imagem , Órbita/lesões , Órbita/cirurgia , Fraturas Orbitárias/complicações , Fraturas Orbitárias/diagnóstico , Fraturas Orbitárias/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Tomografia Computadorizada por Raios X , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: More females are specializing in surgery in Lebanon, but it is not known if a gender bias exists among Lebanese people in their preference of their surgeons. AIMS: This study investigated the preference of Lebanese men and women for the gender of surgeons and explored reasons for their preferences. METHODS: A convenience sample of 1000 Lebanese adults were asked about their preferences for the gender of surgeons of different specialties (paediatrics, cardiology, neurology, orthopaedics, ophthalmology, ear nose and throat, plastic surgery and obstetrics/gynaecology). The association between the participants' sociodemographic characteristics and gender preference for surgeons was examined in bivariate and multivariable regression analyses. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Half of the respondents had no gender preference for their surgeons whatever their speciality. Male surgeons were preferred over females for cardiac (44.2% versus 3.7% respectively), neurological (43.4% versus 4.1%) and orthopaedic procedures (41.9% versus 3.5%) whereas male and female obstetricians/gynaecologists were equally preferred (23.6% and 25.0% respectively). Being male (OR = 0.74, 95% CI: 0.57-0.97) or single (OR = 0.65, 95% CI: 0.44-0.96) decreased the likelihood of choosing a male heart surgeon whereas employment increased that likelihood (OR = 1.37, 95% CI: 1.03-1.83). Perceived competence, reputation and trustworthiness of male surgeons influenced participants' choices whereas the choice of an obstetrician/gynaecologist was related to privacy and comfort. CONCLUSIONS: The preference for female surgeons in Lebanon varies by the type of surgical specialty. Qualitative studies exploring the social determinants of patients' preferences are needed.
Assuntos
Preferência do Paciente/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Líbano , Masculino , Medicina/estatística & dados numéricos , Pessoa de Meia-Idade , Preferência do Paciente/psicologia , Fatores Sexuais , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: Patients with obesity and end-stage renal disease represent a surgical population with multiple comorbidities and high risk for postoperative complications. One method for reducing the incidence of postoperative adverse events in this patient population is to limit the number of operations through combining operations into 1 operative encounter. METHODS: We conducted a retrospective review of adult patients at a single institution who underwent renal transplant, panniculectomy, and at least 1 additional abdominal or pelvic surgery concurrently. For those patients, we collected demographics, intraoperative variables, and postoperative data and analyzed surgical outcomes and postoperative complications. RESULTS: Thirteen patients met inclusion criteria. Most of the patients were female (85%) with ages ranging 33 to 70 years old and mean body mass index of 36.5 (SD 4.7). Three quarters of patients (77%) underwent 3 procedures and the remaining underwent 4 or 5 procedures with a median hospital length of stay of 5 days (range, 3-10 days). There was a single mortality. Overall, 8 patients (61.5%) experienced complications in the first 90 postoperative days. The wound complication rate was 46.2%, the overall readmission rate within 90 days was 38.5%, and the reoperation rate was 30.8%. All patients experienced immediate graft function, and the 12 patients that survived to postoperative day 90 maintained survival at 1 year. CONCLUSION: This study demonstrates that the combination of more than 2 surgical procedures with living donor renal transplant is a possible treatment option in high-risk obese patients in need of multiple operations.