Retroperitoneal sarcoma: the University of Florida experience.

BACKGROUND: Retroperitoneal sarcomas are rare mesenchymal neoplasms. Analysis of their characteristics and their impact upon a particular patient population is of significant importance to the surgeon. From 1970 to 1994, 63 adult patients underwent resection of primary retroperitoneal sarcomas at the University of Florida. STUDY DESIGN: A retrospective analysis was performed to determine the biologic behavior of these tumors, surgical management of primary and recurrent disease, predictive variables influencing survival, and the effect of multimodality therapy. RESULTS: There were 39 females and 24 males and the mean age was 55 years. The median weight of the tumors was 1,815 g (range 25 to 10,800 g). There were 33 percent leiomyosarcomas, 30 percent malignant fibrous histiocytomas, and 22 percent liposarcomas. Low-grade tumors accounted for 46 percent of the total, and grade was a significant predictor of survival (p=0.002). Seventy-eight percent of the lesions were totally resected, and this clearly influenced outcome (p<0.0001). In 75 percent of cases, adjacent organs were resected concurrently, and 34 percent of the tumors involved local vascular structures. Survival was enhanced by multiple resections in the 40 percent of patients who had a recurrence (p=0.0001). None of the adjuvant therapy regimens demonstrated survival advantage. Thirty-one percent of the study group patients were alive and 21 percent were disease free at the conclusion of the study. Median survival has been 41 months after total resection, nine months after debulking, and five months after biopsy only. CONCLUSIONS: Complete resection and low grade continue to be the most important prognostic factors for this tumor. The survival advantage of multiple resections has seldom been noted and justifies an aggressive surgical follow-up.

Prospective evaluation of the giant prosthetic reinforcement of the visceral sac for recurrent and complex bilateral inguinal hernias.

BACKGROUND: Recurrent and complex bilateral inguinal hernias are associated with a high recurrence rate. This study evaluates prospectively the efficacy and safety of giant prosthetic reinforcement of the visceral sac (GPRVS) in a group of patients at high risk for recurrence. METHODS: Sixty-four patients with 124 inguinal hernias (60 bilateral and 4 unilateral) underwent repair using a large polyester mesh based on Stoppa's preperitoneal technique. Mean age was 61 years (63 men and 1 woman), and 69% had one or more comorbid medical conditions. RESULTS: Factors predicating a high risk for recurrence included large hernia size (> or =5 cm; 31%, 20 of 64), failure of one or more previous repairs (39%, 25 of 64), and chronic obstructive pulmonary disease (28%, 18 of 64). Mean operative time was 115 minutes (range 45 to 235). Mean length of stay was 3+/-3 days. There were 2 major and 15 minor complications, no mesh infections, and no death. Follow-up was obtained in 95% (61 of 64). After a mean follow-up of 24 months, the recurrence rate was 1% (1 of 124) per inguinal hernia repaired or 2% (1 of 64) per patient. CONCLUSION: GPRVS is a safe and effective addition to the surgeon's armamentarium to treat selected patients with recurrent or complex bilateral inguinal hernias.

A prospective analysis of 3525 esophagogastroduodenoscopies performed by surgeons.

BACKGROUND: This study was undertaken to evaluate the safety and efficacy of surgeons performing esophagogastroduodenoscopy (EGD) and to use these results to assess existing credentialing guidelines for surgeons. METHODS: A prospective outcomes study was designed to accept input from members of SAGES. End points were the time taken and rate of success in reaching the duodenum, the frequency of arriving at a diagnosis, and complications of EGD as related to operator experience. RESULTS: Information from a total of 3,525 EGDs was prospectively entered into a database between December 2001 and December 2002. Common indications were abdominal pain/nausea/vomiting (34.8%), gastroesophageal reflux disease (24.9%) and dysphagia (17.4%). The findings were inflammation in 1,895 (53.8%), hiatus hernia in 1,010 (28.7%), nonbleeding ulcer in 462 (13.1%), bleeding ulcer in 59 (1.7%), stricture in 344 (9.8%), and polyp/tumor in 206 (5.8%). Biopsies were obtained in 2080 (59.0%). Concomittant procedures performed were dilation in 253 (7.2%), removal of a foreign body (FB) or removal/insertion of a percutaneous endoscopic gastrostomy tube (PEG) in 190 (5.4%), and polypectomy in 59 (1.7%). The EGD was completed to the duodenum in 3282 patients (93.1%) with a mean procedure time of 9.2 min (range 1-60 min). Examination of the duodenum was not attempted in 231 patients for reasons such as previous gastric surgery ( n = 119), obstruction ( n = 58) or because the EGD was done for FB/PEG removal or PEG placement ( n = 36). Attempted EGD could not be completed in 12 patients (0.3%). The most common complication was hypoxia ( n = 57, 1.6%), which was treated with supplemental oxygen and observation. New bleeding occurred in eight patients and the procedure failed to control bleeding in three others. No complications occurred in 3447 patients (97.8%). Completion rates and major complications were not correlated to experience, but there was a significant association between experience and the time required for completion of the procedure ( p < 0.0001). CONCLUSIONS: This study shows that surgeons can perform EGD with a high degree of success and low morbidity. On the basis of this large prospective study, no minimum number of cases could be proposed for credentialing surgeons to safely perform either diagnostic or therapeutic esophagogastroduodenoscopy.

Trends in surgical treatment of breast cancer at an urban teaching hospital: a six-year review.

The treatment of breast cancer at an urban teaching hospital from 1990 to 1995 was analyzed according to age, stage, race, and funding status. Two hundred thirty-eight patients (mean age, 55 years) with newly diagnosed breast cancers were retrospectively identified and reviewed. A larger proportion of all funded patients (F; n = 131) presented with early-stage cancers (ductal carcinoma in situ, stage I) compared to nonfunded (NF, n = 107) (41 vs 25%; P = 0.03). Additionally, there was an increasing rate of early cancers occurring in F over the study interval (40% in 1990 to 69% in 1995), but there was no such increase in NF. There was an increasing trend in the overall use of breast conservation therapy (BCT) over this interval (11.6% of all cancers in 1990, 50.8% in 1994 and 1995). Although F were overall more likely to undergo BCT than NF (40% vs 29%, P = 0.04), there was no statistical difference in the use of BCT for nonadvanced (ductal carcinoma in situ, stage I and II) cancers (44% of F, 46% of NF). Age did not affect the overall use of BCT (36% of patients 55 or older, 35% younger than 55). Mean age was significantly greater in F than in NF (60 vs 49, P < 0.000001), but racial composition did not differ between these two groups. In conclusion, funded status of our patients corresponded with earlier diagnosis, perhaps due to better access to screening. Additionally, neither funding status nor age affected the use of BCT in our patients with nonadvanced cancers. Our rate of BCT far exceeds that seen nationally, perhaps reflecting a trend at academic institutions.

Surgery of breast cancer.

Near the beginning of this century, the aggressive surgical procedure of radical mastectomy to treat breast cancer was proposed by William S. Halsted. Today, the patient with newly diagnosed breast cancer and her surgeon have significantly more varied treatment options. Radical surgical resection has been supplanted by breast conservation therapy. Biopsy methods and the actual surgical techniques continue to be refined. Further developments have emerged in the debates over the efficacy of axillary dissection and sentinel lymph node biopsy. Diverse differences are seen in breast cancer of younger patients due to some fundamental distinctions in their disease. As we approach the next millenium it is clear that breast cancer is curable in a large percentage of women. While attention is turning to the investigation of the biologic and genetic factors involved with this disease, surgical regimens maintain a preeminent role in the overall quest for cure.