5320 articles - 08.09.10
1: Surgery. 2010 Sep 2; [Epub ahead of print]
Sahora K, Kuehrer I, Eisenhut A, Akan B, Koellblinger C, Goetzinger P, Teleky B, Jakesz R, Peck-Radosavljevic M, Ba'ssalamah A, Zielinski C, Gnant M.
Department of Surgery, Medical University of Vienna, Vienna, Austria.
BACKGROUND: Neoadjuvant chemotherapy can facilitate pancreatic resection in patients with initially unresectable pancreatic cancer (PC). We report the results of a phase II trial of gemcitabine-oxaliplatin neoadjuvant chemotherapy for patients with locally advanced, nonmetastatic PC. METHODS: A prospective, phase II clinical trial using neoadjuvant chemotherapy, consisting of gemcitabine (900 mg/m(2)) and oxaliplatin (60 mg/m(2)) given as intravenous infusion once a week at day 1 of each treatment cycle (NeoGemOx protocol). Patients received 6-9 cycles of chemotherapy. Those patients with sufficient tumor regression subsequently underwent pancreatic resection and were followed postoperatively to assess long-term survival. RESULTS: A total of 33 patients were eligible and were included in the intent-to-treat and evaluable population. On centralized review of the imaging studies, 18 patients had unresectable disease at inclusion, and 15 patients had borderline resectable PC. Eventually, 13 patients (39%) had a curative resection after neoadjuvant therapy. The R0 resection rate was 69%. Median overall survival of patients who underwent tumor resection was 22 months (95% confidence interval [CI], 14-30) compared with 12 months (95% CI, 9-15) for those without resection (P = .046). The median recurrence-free survival rate after resection was 10 months (95% CI, 4-17). CONCLUSION: Neoadjuvant gemcitabine plus oxaliplatin is well tolerated and safe. Substantive tumor regression occurs in some patients with locally advanced PC treated with this neoadjuvant protocol, offering the potential for curative resection and improvement in overall survival. Additional studies involving the NeoGemOx protocol should be considered to further evaluate the safety and efficacy of this combination. Copyright (c) 2010 Elsevier Inc. All rights reserved.
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PMID: 20817204 [PubMed - as supplied by publisher]2: Br J Surg. 2010 Sep 1; [Epub ahead of print]
Layfield DM, Agrawal A, Roche H, Cutress RI.
Southampton Breast Surgical Unit, Southampton University Hospitals Trust, Southampton, UK.
BACKGROUND:: Sentinel lymph node biopsy (SLNB) reduces the morbidity of axillary clearance and is the standard of care for patients with clinically node-negative breast cancer. The ability to analyse the sentinel node during surgery enables a decision to be made whether to proceed to full axillary clearance during primary surgery, thus avoiding a second procedure in node-positive patients. METHODS:: Current evidence for intraoperative sentinel node analysis following SLNB in breast cancer was reviewed and evaluated, based on articles obtained from a MEDLINE search using the terms 'sentinel node', 'intra-operative' and 'breast cancer'. RESULTS AND CONCLUSION:: Current methods for evaluating the sentinel node during surgery include cytological and histological techniques. Newer quantitative molecular assays have been the subject of much recent clinical research. Pathological techniques of intraoperative SLNB analysis such as touch imprint cytology and frozen section have a high specificity, but a lower and more variably reported sensitivity. Molecular techniques are potentially able to sample a greater proportion of the sentinel node, and could have higher sensitivity. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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PMID: 20812233 [PubMed - as supplied by publisher]3: J Vasc Surg. 2010 Aug 27; [Epub ahead of print]
Antoniou GA, Riga CV, Mayer EK, Cheshire NJ, Bicknell CD.
BACKGROUND:: Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery. METHODS:: A systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords "surgical robotics," "robotic surgery," "robotics," "computer assisted surgery," and "vascular surgery" or "endovascular" for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken. RESULTS:: Seventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited. CONCLUSIONS:: Robotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery. Crown Copyright (c) 2010. Published by Mosby, Inc. All rights reserved.
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PMID: 20801611 [PubMed - as supplied by publisher]4: J Vasc Surg. 2010 Aug 25; [Epub ahead of print]
Greenberg RK, Qureshi M.
A great deal of attention has been given to the use of endografts in anatomy that involves critical aortic branches, such as the visceral segment and the aortic arch. Hybrid techniques and other methods to preserve flow into such vessels have been met with questionable success. The recent publication of the endovascular aneurysm repair (EVAR) trial data, particularly their screening registry, indicates that the number of patients with aneurysms involving critical vessels is considerable compared with aneurysms with adequate infrarenal neck. This has renewed corporate interest in developing devices that will address these complex problems. Branches designed to preserve iliac flow, fenestrated and branched devices for the visceral aortic segment, and arch branch devices have all been used clinically with a variety of platforms. This article reviews the devices and treatment strategies that are being proposed or studied by both large and small companies. Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
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PMID: 20800422 [PubMed - as supplied by publisher]5: Br J Surg. 2010 Aug 26; [Epub ahead of print]
Pascual M, Alonso S, Pares D, Courtier R, Gil MJ, Grande L, Pera M.
Colorectal Surgery Unit, Department of Surgery, Hospital del Mar, Barcelona, Spain.
BACKGROUND:: Several studies have suggested that laparoscopy might confer an oncological advantage in patients undergoing surgery for colonic cancer. A decreased inflammatory and angiogenic response has been proposed. This study compared the local and systemic inflammatory and angiogenic responses after open and laparoscopic surgery for colonic cancer. METHODS:: Some 122 patients with colonic cancer were randomized to open or laparoscopic colectomy. Levels of interleukin (IL) 6 and vascular endothelial growth factor (VEGF) were measured in serum and peritoneal fluid at baseline, then at 4, 12, 24 and 48 h and on day 4 after surgery. Samples obtained on day 4 were tested in an in vitro angiogenesis assay, with measurement of number of capillaries per field and capillary length. RESULTS:: The serum IL-6 level was lower in the laparoscopic group at 4 h (mean(s.d.) 124(110) versus 244(326) pg/dl after open colectomy; P = 0.027). The serum VEGF concentration was also lower in the laparoscopic group at 48 h and day 4 (430(435) versus 650(686) pg/dl; P = 0.001). Overall, local IL-6 and VEGF levels were significantly higher than serum levels but there were no differences between groups. In vitro, postoperative serum and peritoneal fluid samples were potently angiogenic but there were no differences between open surgery and laparoscopy. Rates of tumour recurrence and survival were similar in the two groups. CONCLUSION:: Despite differences in postoperative serum levels of IL-6 and VEGF after open and laparoscopic surgery in patients with colonic cancer, the angiogenic response is comparable in both surgical approaches. Registration number: ISRCTN55624793 (http://www.controlled-trials.com). Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.">Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20799296&dopt=ExternalLink
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PMID: 20799296 [PubMed - as supplied by publisher]6: Br J Surg. 2010 Aug 26; [Epub ahead of print]
Ball EL, Walsh SR, Tang TY, Gohil R, Clarke JM.
Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
BACKGROUND:: Temporal artery (TA) biopsy is the current standard for diagnosing temporal arteritis, but has limited sensitivity. Colour duplex ultrasonography is a newer, non-invasive method of diagnosing temporal arteritis. METHODS:: A systematic review was performed of trials comparing TA biopsy with duplex ultrasonography. Duplex results (halo sign, stenosis or vessel occlusion) were compared with either TA biospy findings or the American College of Rheumatology research criteria for diagnosing temporal arteritis. Trials were identified from MEDLINE, Embase and the Cochrane Library trials register. The performance of duplex ultrasonography was assessed with weighted independent sensitivity and specificity values, and summary receiver operating characteristic curve analysis. RESULTS:: There were 17 eligible studies containing 998 patients. When the halo sign on duplex imaging was compared with TA biopsy, the sensitivity was 75 (95 per cent confidence interval 67 to 82) per cent and the specificity was 83 (78 to 88) per cent. There was no heterogeneity across the eligible studies. CONCLUSION:: Duplex ultrasonography was relatively accurate for diagnosing temporal arteritis. It should become the first-line investigation, with biopsy reserved for patients with a negative scan. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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PMID: 20799290 [PubMed - as supplied by publisher]7: Br J Surg. 2010 Aug 26; [Epub ahead of print]
Watanabe M, Murakami M, Nakao K, Asahara T, Nomoto K, Tsunoda A.
Department of Gastroenterological and General Surgery, Showa University School of Medicine, Tokyo, Japan.
BACKGROUND:: This study investigated the influence of mechanical bowel preparation (MBP) on faecal microflora, using rRNA-targeted reverse transcription-quantitative polymerase chain reaction in patients undergoing colonic cancer resection. METHODS:: Forty-two patients undergoing elective colonic surgery were randomized into MBP or no-MBP groups (21 in each group). The main outcome was the bacterial microflora and faecal organic acid content of faecal material obtained at operation. RESULTS:: Clinical characteristics were similar in the two groups. Bowel content in the resected specimens did not differ significantly. The count of bacterial microflora, such as Bifidobacterium and total Lactobacillus, in both intraoperative faecal material and first material after surgery was significantly lower in the MBP group than the no-MBP group (P < 0.050). Levels of faecal organic acids, such as acetic acid, propionic acid and butyric acid, in intraoperative faecal material were significantly lower, and levels of lactic acid were significantly higher, in the MBP group than in the no-MBP group (P < 0.050). The succinic acid level was significantly higher after surgery than before operation in the MBP group (P = 0.008). CONCLUSION:: Preoperative MBP caused an imbalance in the bowel microflora, suggesting that it offers no advantages in terms of enterobacterial microflora for patients undergoing colonic cancer resection. Registration number: UMIN000003153 (http://www.umin.ac.jp/ctr/index.htm). Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.">Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20799286&dopt=ExternalLink
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PMID: 20799286 [PubMed - as supplied by publisher]8: Surgery. 2010 Aug 24; [Epub ahead of print]
Onders RP, Khansarinia S, Weiser T, Chin C, Hungness E, Soper N, Dehoyos A, Cole T, Ducko C.
Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH.
BACKGROUND: Diaphragm pacing (DP) can replace mechanical ventilation in tetraplegics and in trials has assisted respiration in amyotrophic lateral sclerosis patients. This report describes results of DP in patients with cardiac pacemakers. METHODS: Prospective, single-center and multicenter, nonrandomized, controlled, interventional protocols under U.S. Food and Drug Administration and/or institutional review board approval were evaluated. Patients underwent laparoscopic diaphragm motor point mapping to identify optimal electrode site for implantation. With diaphragm conditioning, patients were weaned from their ventilator. Perioperative and long-term assessments between the cardiac pacemakers and DP were analyzed for any device-to-device interactions. RESULTS: Over 300 subjects were implanted from 2000 to 2010. Twenty tetraplegics with cardiac pacemakers and DP were analyzed from 6 sites. Subjects ranged from 19 to 61 years old with DP implantation 6 months to 24 years postinjury. There were no immediate or long-term device to device interactions. All patients achieved diaphragm-paced tidal volumes exceeding their basal requirements and, after conditioning, all patients could go >4 hours without mechanical ventilators; 71% could go 24 hours continuously. CONCLUSION: DP can be safely implanted in tetraplegics having cardiac pacemakers. Applications for temporary use of DP to maintain diaphragm type 1 muscle fiber and improve posterior lobe ventilation may benefit complex critical care patients. Copyright (c) 2010 Elsevier Inc. All rights reserved.
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PMID: 20797750 [PubMed - as supplied by publisher]9: Ann Surg. 2010 Sep;252(3):452-8; discussion 458-9.
Shackford SR, Hyman N, Ben-Jacob T, Ratliff J.
Department of Surgery, College of Medicine, University of Vermont, Burlington, VT, USA. shackford.steven@scrippshealth.org
OBJECTIVE(S): Profiling of hospitals using risk-adjusted mortality rates as a measure of quality is becoming increasingly frequent. We sought to determine the validity of this approach by comparing the risk-adjusted predicted mortality to the findings of concurrent peer review and retrospective chart review of deaths that occur on a general surgery service. METHODS: Consecutive patients admitted to a busy general surgery service from January 2000 to January 2006 were prospectively entered into the Surgical Activity Tracking System. Rigorous, systematic peer review was performed concurrently by service members on all deaths. Adjudication was later validated by an independent senior surgeon. Three methodologies of risk adjustment (University Health Consortium, Physiological and Operative Severity Score for the enUmeration of Mortality, and the Charlson index) were used and compared the "excess mortality" predicted by each to the number of potentially preventable deaths determined by peer review. RESULTS: A total of 9623 patients were admitted and 75 died (0.7%). University Health Consortium and Physiological and Operative Severity Score predicted an excess mortality of 62 and 65 deaths, respectively; Charlson predicted that 73% of the cohort would be dead in 1 year. Concurrent and retrospective peer review found that death was potentially preventable in only 22 and 21 patients, respectively. CONCLUSIONS: Peer adjudication and extensive clinical review adds much to the analysis of an adverse outcome, similar to the "black box" in an airplane crash. Although methods of risk adjustment may be helpful in identifying patients for peer review, they should be used for internal process improvement and not published as metrics of hospital or provider performance.
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PMID: 20739845 [PubMed - in process]10: J Vasc Surg. 2010 Aug 21; [Epub ahead of print]
Kurtoglu M, Koksoy C, Hasan E, Akcali Y, Karabay O, Filizcan U; TROMBOTEK Study Group.
Department of General Surgery, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
OBJECTIVE: The present study was designed to evaluate the long-term efficacy and safety of once-daily enoxaparin plus warfarin for the outpatient ambulatory treatment of lower-limb deep venous thrombosis (DVT). METHODS: A total of 246 patients, comprising 128 men (mean age, 54.28 +/- 16.48 years) and 118 women (mean age, 50.11 +/- 16.47 years) with symptomatic lower extremity DVT, were included in this open-label, single-arm, multicenter, phase IV clinical trial conducted at 14 centers in Turkey. All patients were administered subcutaneous enoxaparin (1.5 mg/kg, once-daily) until international normalized ratio (INR) levels reached to 2 to 3, followed by oral warfarin (5 mg/d) for at least 3 months and elastic compression stockings (30-40 mm Hg). Clinical signs (leg circumference), symptoms (edema, pain, tenderness), recanalization rates upon duplex ultrasound examination, laboratory findings (D-dimer and INR levels), and postthrombotic syndrome status with CEAP classification were the efficacy parameters evaluated every 3 months during 18 months of follow-up. Safety end points included minor and major bleeding as well as serious adverse events. RESULTS: Ambulatory treatment with enoxaparin plus warfarin significantly reduced physical symptoms, including tenderness, edema, pain (P < .001), and the circumference of the affected leg (P < .001). The leg circumference difference in almost all patients was <1.5 cm at the end of 18 months (P < .001). Recanalization rates for occluded iliofemoral vein were 76.1% at 3 months and 86.5% at 18 months (P < .001). An early and significant decrease obtained in D-dimer levels on day 10 continued to decline significantly until month 6 and remained unchanged afterwards (P < .001). Of four patients diagnosed with major bleeding during oral anticoagulant use, three recovered with conservative treatment (reduction in hemoglobin levels in 2 developed at visit 2 [day 10] and intracranial bleeding in 1 developed at visit 3 [day 30]), and one patient required a hysterectomy after menorrhagia developed at visit 7 (month 18). Two of the 65 (9.9%) adverse events documented were serious adverse events, but none of the serious adverse events leading to death were related to the study medications. CONCLUSION: Ambulatory treatment with enoxaparin plus warfarin seems to be effective in symptomatic healing and in clinical improvement by reducing thrombus formation and organization at all levels of lower extremity venous system with DVT, without a significant major bleeding risk. Therefore, the results of our conventional conservative treatment are in line with 1A level evidence reported in the recent American College of Chest Physicians guideline. Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
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PMID: 20732787 [PubMed - as supplied by publisher]11: Br J Surg. 2010 Aug 20; [Epub ahead of print]
Chalmers RT, Darling Iii RC, Wingard JT, Chetter I, Cutler B, Kern JA, Hart JC.
Royal Infirmary of Edinburgh, Edinburgh, UK.
BACKGROUND:: This study evaluated the safety and haemostatic effectiveness of a fibrin sealant (EVICEL() Fibrin Sealant (Human)) during vascular surgery. METHODS:: This prospective randomized controlled trial compared the haemostatic effectiveness of fibrin sealant (75 patients) or manual compression (72) in polytetrafluoroethylene (PTFE) arterial anastomoses. The primary endpoint was the absence of bleeding at the anastomosis at 4 min after randomization. Secondary endpoints included haemostasis at 7 and 10 min, treatment failures and the incidence of complications potentially related to bleeding. Adverse events were recorded. RESULTS:: A higher percentage of patients who received fibrin sealant versus manual compression achieved haemostasis at 4 min (85 versus 39 per cent respectively; odds ratio 11.34, 95 per cent confidence interval 4.67 to 27.52; P < 0.001). Similarly, a higher percentage of patients who received fibrin sealant achieved haemostasis at 7 and 10 min (both P < 0.001). The incidence of treatment failure was lower in the fibrin sealant group (P < 0.001). The rate of complications potentially related to bleeding was similar (P = 0.426). Some 64 per cent of patients who received fibrin sealant experienced at least one adverse event, compared with 71 per cent who received manual compression. CONCLUSION:: This fibrin sealant was safe, and significantly shortened the time to haemostasis in vascular procedures using PTFE. Registration number: NCT00154141 (http://www.clinicaltrials.gov). Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.">Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20730858&dopt=ExternalLink
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PMID: 20730858 [PubMed - as supplied by publisher]12: Ann Surg. 2010 Aug 19; [Epub ahead of print]
Winters ZE, Benson JR, Pusic AL.
From the *Clinical Sciences at South Bristol, Breast Reconstruction Quality of Life Group, University Hospitals Bristol NHS Foundation Trust, University of Bristol, Bristol, United Kingdom; daggerCambridge University Teaching Hospitals NHS Trust and University of Cambridge; and double daggerDepartment of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY.
BACKGROUND:: Advances in breast cancer diagnosis and management have produced significant improvements in disease-free and breast cancer related survival. Consequently, there is increasing focus on the quality of long-term cancer survivorship. Of the 44,000 women diagnosed annually in the United Kingdom, 30% to 40% are required to undergo mastectomy. During the past 30 years, significant technical advances in breast reconstruction have increased performance of this surgical practice as a means to potentially improve health-related quality of life (HRQoL) for breast cancer survivors. Breast reconstruction studies increasingly aim to assess more discriminating outcomes based on the patients' own perception of the surgical result and its effect on HRQoL. This incremental output in HRQoL evaluation is being fuelled by both healthcare providers and official bodies such as the Food and Drug Administration, together with demands for more comprehensive comparative effectiveness data to permit fully informed consent by patients. METHODS:: In this systematic review, the authors apply inclusion and exclusion criteria to effectively screen 1012 abstracts identified in the field of HRQoL in breast reconstruction between 1978 and 2009. Each study was evaluated with respect to its design and statistical methodology. Each was reviewed with a recommended standard checklist of methodological requirements as described by Efficace et al (J Clin Oncol. 2003;21:3502-3511). RESULTS:: A total of 34 papers that included HRQL outcomes in breast reconstruction were identified and reviewed in detail. The majority of studies were retrospective in nature with significant inherent limitations. Specifically, they were compromised by potentially biased patient recall. Most of these studies lacked both an a priori outcome of interest and statistical rigor jeopardizing estimations of potential effect size. In addition, more than 90% of the studies failed to report or describe missing data. Thirteen studies provided level I (n = 2) and II (n = 11) evidence. While these studies benefited from more robust design, the majority used generic instruments such as 36-item short form (SF-36), which may not be sufficiently sensitive to measure changes consequent to breast reconstruction (ie, effect on body image or psychosocial well-being). Furthermore, these studies were generally underpowered to detect meaningful clinical difference or to permit subgroup analyses. Further limitations included reliance on single center design that may negatively impact generalizability and deficiencies in reporting the number and types of surgical complications, which potentially has an effect on HRQoL outcomes. CONCLUSIONS:: This systematic review reveals a tendency for sound scientific methodology in HRQoL to be undermined by poorly designed and underpowered studies. In the current healthcare environment, patients and providers increasingly seek meaningful data to guide clinical decisions; policy makers are similarly in need of a rigorous patient-centered, comparative effectiveness data to inform national level decision-making. In light of this and the limitations of the existing published data, there is a pressing need for further Level I and II evidence in the form of randomized controlled trials as well as well-designed, multicenter prospective longitudinal studies in breast reconstruction. Such studies should incorporate sensitive and condition-specific patient-report outcome measures, provide adequate sample sizes, and respect established guidelines for rigorous HRQoL methodology.
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PMID: 20729711 [PubMed - as supplied by publisher]13: J Am Coll Surg. 2010 Aug 20; [Epub ahead of print]
Chua TC, Al-Zahrani A, Saxena A, Liauw W, Zhao J, Morris DL.
Department of Surgery, University of New South Wales, Kogarah, Sydney, Australia.
BACKGROUND: Cytoreductive surgery and perioperative intraperitoneal chemotherapy (PIC) is recognized as an effective treatment modality for patients with pseudomyxoma peritonei. This study investigates its role as a secondary definitive treatment procedure after earlier primary treatments. STUDY DESIGN: Patients with pseudomyxoma peritonei undergoing secondary cytoreduction combined with PIC were identified from a prospective database. Retrospective analysis investigated the outcomes, prognostic factors, critical time points, and impact of malignant dedifferentiation. Survival analysis was performed via the Kaplan-Meier method and compared via the log-rank test. RESULTS: The median time to progression after secondary cytoreduction was 28 months (95% CI 14 to 41 months), median survival was 97 months (95% CI 82 to 113 months), and 10-year survival was 25%. Median overall survival from initial diagnosis was 17 years and 10-year survival rate was 75%. Forty-five patients remained disease free (63%). Requiring an urgent treatment (waiting time < 60 days) after disease progression (p = 0.045) and having moderate or severe symptoms (p = 0.033) were associated with a shorter time to progression. Improved survival was associated with patients who had low-grade tumors (p = 0.029), and those who required less urgent treatment (wait > 30 days) after disease progression (waiting up to 15 days, p = 0.010; waiting up to 30 days, p = 0.005). Malignant dedifferentiation appeared to affect survival from initial diagnosis (p = 0.062) and after secondary cytoreduction (p = 0.006). CONCLUSIONS: Secondary cytoreduction with PIC achieves long-term survival. Tumors that undergo malignant dedifferentiation appear to adversely affect survival, and this may support the rationale for early definitive treatment with cytoreduction and PIC. Copyright (c) 2010 American College of Surgeons. All rights reserved.
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PMID: 20729102 [PubMed - as supplied by publisher]14: Surgery. 2010 Aug 13; [Epub ahead of print]
Fronza JS, Linn JG, Nagle AP, Soper NJ.
Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
BACKGROUND: The advent of single incision laparoscopic surgery has brought renewed attention to cholecystectomy due to the promise of improved cosmesis and less parietal trauma. Small series have demonstrated the feasibility of single incision laparoscopic cholecystectomy (LC). Our series adds to the literature by demonstrating a variety of ancillary techniques that may be employed to perform single incision LC safely, and compares our early experience with that of our standard LC. METHODS: We performed a retrospective chart review of patients who underwent single incision LC between February 2008 and April 2009. These patients were compared with an equal number of randomly selected patients undergoing LC during the same period. We identified 25 attempted single incision LC, which were included in our analysis. RESULTS: Single incision LC was successfully performed in 21 patients, with only 4 patients requiring conversion to LC. No patients in either group had acute cholecystitis. The critical view of safety was documented in 20 of 21 patients undergoing a successful single incision LC compared with all patients undergoing LC. Operative time was significantly longer in the single incision group. Complications were minor and comparable between the 2 groups. In 9 patients (43%) a suture passer helped to retract the gallbladder. In 8 patients (38%) 1 or 2 Prolene sutures placed by means of a Keith needle helped to retract the gallbladder over the liver and/or helped to retract the infundibulum. In 2 patients, >/=1 supplemental 5-mm port was utilized. In 5 patients (24%), no supplementary retraction was necessary. CONCLUSION: Single incision LC is technically more challenging than LC, but can be performed safely by experienced laparoscopic surgeons with results comparable with LC. Copyright (c) 2010 Mosby, Inc. All rights reserved.
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PMID: 20708764 [PubMed - as supplied by publisher]15: J Vasc Surg. 2010 Aug 7; [Epub ahead of print]
Nicolai SP, Hendriks EJ, Prins MH, Teijink JA; EXITPAD study group.
Maxima Medical Center Eindhoven/Veldhoven, Department of Surgery, Veldhoven, The Netherlands.
BACKGROUND:: The first-line intervention for intermittent claudication is usually supervised exercise therapy (SET). The literature describes a range of exercise programs varying in setting, duration, and content. The purpose of the present study was to examine the exercise protocols offered and to identify the impact of the intensity of the SET programs (in terms of frequency, duration, and type of exercise) on improvements in walking distance (response) in the first 3 months. The present study is part of the Exercise Therapy in Peripheral Arterial Disease (EXITPAD) study, a multicenter randomized clinical trial comparing the effects of SET provided by regional physiotherapists, with or without daily feedback, on the level of activities with the effects of walking advice. METHODS:: The analysis included patients randomized to receive SET with or without feedback. The physical therapists administering the SET were asked to fill out therapy evaluation sheets stating frequency, duration, and type of exercises. The relationship between training volume and the impact on walking distance was explored by dividing training volume data into tertiles and relating them to the median change in maximum walking distance at 3 and 12 months. RESULTS:: Data of 169 patients were included in the analysis. A SET program consisting of at least two training sessions per week each lasting over 30 minutes, during the first 3 months of a 1-year program tailored to individual patients' needs led to better results in terms of walking distance after 3 and 12 months than the other variants. The results of our analysis dividing training volume into tertiles suggest that there is a relationship between training volume and improvement in walking distance and that at least 590 minutes of training should be offered in the first 3 months. No differences were found between program involving only walking and a combination of exercises, nor between individual and group training. CONCLUSION:: A SET programs consisting of at least two training sessions a week, each lasting over 30 minutes, should be offered during the first 3 months of the SET program to optimize improvement in terms of maximum walking distance. Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
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PMID: 20692797 [PubMed - as supplied by publisher]16: J Vasc Surg. 2010 Aug 7; [Epub ahead of print]
Feng Y, Schlosser FJ, Sumpio BE.
Section of Vascular Surgery, Yale University School of Medicine.
OBJECTIVE: Diabetic peripheral neuropathy is a major complication of diabetes mellitus (DM) and is the leading cause of foot ulceration and lower extremity amputations (LEAs). The purpose of this systematic review is to evaluate current evidence regarding the prognostic value of the Semmes Weinstein monofilament examination (SWME) in predicting foot ulceration and LEA in patients with DM. METHODS: The MEDLINE/PubMed database was searched through November 2009 for articles pertaining to diabetic foot and SWME with no language or publication date restrictions. Prognostic studies with original data assessing the predictive value of SWME for foot ulceration or LEA in patients with DM were included in the selection. Data were systematically extracted and analyzed by two independent investigators. Absolute risks and relative risks were determined for each study. RESULTS: Of the 863 studies identified, nine articles were relevant, involving 11,007 patients with DM. Six studies were identified that assessed the prognostic value of SWME regarding diabetic foot ulceration. The relative risk for patients with a positive SWME result versus those with a negative result ranged from 2.5 (95% confidence interval [CI], 2.0 to 3.2) to 7.9 (95% CI, 4.4 to 14.3) in the identified studies with follow up between 1 and 4 years. Three of the studies assessed the risk of LEA with a positive SWME result. The relative risk for LEA ranged from 1.7 (95% CI, 1.1 to 2.6) to 15.1 (95% CI, 4.3 to 52.6) with follow-up between 1.5 and 3.3 years. CONCLUSIONS: All nine studies found SWME to be a significant and independent predictor of future foot ulceration or likely of future LEA as well in patients with DM. Therefore, SWME is an important evidence-based tool for predicting the prognosis of patients with diabetic foot, thus enabling improved patient selection for early intervention and management. More research should be conducted to elucidate the relationship between SWME and LEA. Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20692793&dopt=ExternalLink
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PMID: 20692793 [PubMed - as supplied by publisher]17: BMC Surg. 2010 Aug 6;10:25.
van de Wall BJ, Draaisma WA, Consten EC, van der Graaf Y, Otten MH, de Wit GA, van Stel HF, Gerhards MF, Wiezer MJ, Cense HA, Stockmann HB, Leijtens JW, Zimmerman DD, Belgers E, van Wagensveld BA, Sonneveld ED, Prins HA, Coene PP, Karsten TM, Klaase JM, Statius Muller MG, Crolla RM, Broeders IA; Dutch Diverticular Disease (3D) Collaborative Study Group.
Department of Surgery, Meander Medical Center Amersfoort, The Netherlands.
BACKGROUND: Persisting abdominal complaints are common after an episode of diverticulitis treated conservatively. Furthermore, some patients develop frequent recurrences. These two groups of patients suffer greatly from their disease, as shown by impaired health related quality of life and increased costs due to multiple specialist consultations, pain medication and productivity losses.Both conservative and operative management of patients with persisting abdominal complaints after an episode of diverticulitis and/or frequently recurring diverticulitis are applied. However, direct comparison by a randomised controlled trial is necessary to determine which is superior in relieving symptoms, optimising health related quality of life, minimising costs and preventing diverticulitis recurrences against acceptable morbidity and mortality associated with surgery or the occurrence of a complicated recurrence after conservative management.We, therefore, constructed a randomised clinical trial comparing these two treatment strategies. METHODS/DESIGN: The DIRECT trial is a multicenter randomised clinical trial. Patients (18-75 years) presenting themselves with persisting abdominal complaints after an episode of diverticulitis and/or three or more recurrences within 2 years will be included and randomised. Patients randomised for conservative treatment are treated according to the current daily practice (antibiotics, analgetics and/or expectant management). Patients randomised for elective resection will undergo an elective resection of the affected colon segment. Preferably, a laparoscopic approach is used.The primary outcome is health related quality of life measured by the Gastro-intestinal Quality of Life Index, Short-Form 36, EQ-5D and a visual analogue scale for pain quantification. Secondary endpoints are morbidity, mortality and total costs. The total follow-up will be three years. DISCUSSION: Considering the high incidence and the multicenter design of this study, it may be assumed that the number of patients needed for this study (n = 214), may be gathered within one and a half year.Depending on the expertise and available equipment, we prefer to perform a laparoscopic resection on patients randomised for elective surgery. Should this be impossible, an open technique may be used as this also reflects the current situation. TRIAL REGISTRATION: (Trial register number: NTR1478).
Publication Types: Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20691040&dopt=ExternalLink
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PMID: 20691040 [PubMed - in process]18: Am J Surg. 2010 Aug;200(2):291-7.
Dedemadi G, Sgourakis G, Radtke A, Dounavis A, Gockel I, Fouzas I, Karaliotas C, Anagnostou E.
Surgical Department of "A. Fleming" General Hospital, Athens, Greece. gdedemadi@yahoo.gr
BACKGROUND: The objective of this study was to examine the outcomes of comparisons between laparoscopic and open mesh repairs in the setting of recurrent inguinal hernia. METHODS: The electronic databases MEDLINE, Embase, Pubmed, and the Cochrane Library were used to search for articles from 1990 to 2008. The present meta-analysis pooled the effects of outcomes of a total of 1,542 patients enrolled into 5 randomized controlled trials and 7 comparative studies, using classic and modern meta-analytic methods. RESULTS: Significantly fewer cases of hematoma/seroma formation were observed in the laparoscopic group in comparison with the Lichtenstein group (odds ratio, .38; .15-.96; P = .04). A matter of great importance is the higher relative risk of overall recurrence in the transabdominal preperitoneal group compared with the totally extraperitoneal group (relative risk, 3.25; 1.32-7.9; P = .01). CONCLUSIONS: Laparoscopic versus open mesh repair for recurrent inguinal hernia was equivalent in most of the analyzed outcomes. 2010 Elsevier Inc. All rights reserved.
Publication Types: Comparative Study Meta-Analysis
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20678621&dopt=ExternalLink
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PMID: 20678621 [PubMed - indexed for MEDLINE]19: J Vasc Surg. 2010 Aug;52(2):499-507.
Schneider PA, Naylor AR.
Division of Vascular Therapy, Kaiser Foundation Hospital, Honolulu, Hawaii 96819, USA. Peter.Schneider@kp.org
Vascular surgery has matured to the point that there exists robust bodies of literature exploring many of our therapies. However, this evidence is but one of the factors that dictate medical practice. Others include local patient demographics, the practical implications of healthcare delivery, and an individual surgeon's interpretation of this evidence, which can be somewhat subjective. As a result, there are numerous examples of vascular specialists' practice patterns differing depending on their geographic location. Recognizing this, the Editors of the Journal of Vascular Surgery and the European Journal of Vascular and Endovascular Surgery have developed a series of Trans-Atlantic Debates to explore these instances. The inaugural debate explores the controversial question of how best to manage asymptomatic carotid artery stenoses. Our debators, Peter Schneider and Ross Naylor, offer reasoned and passionate arguments to defend their differing approaches. We trust that this addition to our journals will prove enlightening and, perhaps, entertaining. Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20670781&dopt=ExternalLink
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PMID: 20670781 [PubMed - indexed for MEDLINE]20: J Vasc Surg. 2010 Aug;52(2):298-302.
Jones C, Badger SA, Boyd CS, Soong CV.
Vascular and Endovascular Surgery Unit, Belfast City Hospital, Belfast, Ireland. cjones82@hotmail.co.uk
OBJECTIVE: Endovascular aneurysm repair (EVAR) exposes patients to radiation during the procedure and in subsequent follow-up. The study goal was to calculate the radiation dose in our unit and compare it against other published data and national guidelines. METHODS: All EVAR procedures were identified from a prospectively maintained database. Radiation dose, screening time, and volume of intravenous contrast during the procedure were reviewed. Radiation exposure from subsequent computed tomography (CT) imaging was included in the overall exposure. Results are expressed as mean +/- standard deviation. RESULTS: From October 1998 to October 2008, 320 elective patients underwent EVAR. Mean screening time was 29.4 +/- 23.3 minutes, and the radiation dose was 11.7 +/- 7.1 mSv. The EVAR was an emergency in 64 patients. The mean screening time was 22.9 +/- 18.2 minutes, and the radiation dose was 13.4 +/- 8.6 mSv. During the first postoperative year, follow-up CT scans exposed the patients to 24.0 mSv, with 8.0 mSv in subsequent years. Abdominal radiographs added an additional 1.8 mSv each year. CONCLUSION: EVAR and the follow-up investigations involve substantial amounts of radiation, with well-recognized carcinogenic risks. Because patient safety is paramount, radiation exposure should be minimized. This may be possible by standardizing radiation exposure throughout the United Kingdom by implementing national guidelines and considering other imaging modalities for follow-up. Copyright (c) 2010. Published by Mosby, Inc.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20670773&dopt=ExternalLink
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PMID: 20670773 [PubMed - indexed for MEDLINE]