摘要:

ObjectiveTo assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome.MethodsDemographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed.ResultsMalignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality.ConclusionsOver the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases.Summary Background DataThe rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results.MethodsSince 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire.ResultsDuring the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology.ConclusionsIntegration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo analyze a large cohort of patients with stage III colon cancer to determine whether subgroup stratification better defines outcome.Summary Background DataThe Tumor (T), Node (N), Metastasis (M) system is based on depth of tumor invasion into the colonic wall, the number of regional lymph nodes involved, and distant metastasis. Traditionally, colon cancer has been designated as stage III based on nodal involvement regardless of the depth (T1–4) of tumor penetration. Treatment decisions have been based on nodal involvement with less emphasis on colonic wall penetration in stage III patients.MethodsPatients (n = 50,042) with stage III colon cancer reported to the National Cancer Data Base from 1987 through 1993 were analyzed. Observed survival was calculated by actuarial life table methods for three new node-positive subgroups (IIIA: T1/2, N1; IIIB: T3/4, N1; IIIC: any T, N2). The Cox proportional hazards model was used to test the prognostic strength of selected covariates.ResultsThree distinct subcategories within a traditional stage III cohort of colonic cancer were identified. Five-year observed survival rates for these three subcategories were 59.8%, IIIA; 42.0%, IIIB; and 27.3%, IIIC. Differences between subgroups were significant (P< .0001). Similar differences were calculated after stratification for treatment. A multivariate proportional hazards model identified the new stage III subgroups, modality of the first course of therapy, patient age, and tumor grade as significant independent prognostic covariates.ConclusionsThe current stage III designation of colon cancer excludes prognostic subgroups stratified for mural penetration (T1–4) or nodal involvement (N1 vs. N2). Analysis of a large data set supports stratification into three subsets, confirming the benefit of adjuvant chemotherapy in each subgroup. This strategy should be used in the reporting and staging of node-positive colon cancers.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveUsing a prospective randomized study to assess postoperative morbidity and pancreatic function after pancreaticoduodenectomy with pancreaticojejunostomy and duct occlusion without pancreaticojejunostomy.Summary Background DataPostoperative complications after pancreaticoduodenectomy are largely due to leakage of the pancreaticoenterostomy. Pancreatic duct occlusion without anastomosis of the pancreatic remnant may prevent these complications.MethodsA prospective randomized study was performed in a nonselected series of 169 patients with suspected pancreatic and periampullary cancer. In 86 patients the pancreatic duct was occluded without anastomosis to pancreatic remnant, and in 83 patients a pancreaticojejunostomy was performed after pancreaticoduodenectomy. Postoperative complications were the endpoint of the study. All relevant data concerning patient demographics and postoperative morbidity and mortality as well as endocrine and exocrine function were analyzed. At 3 and 12 months after surgery, evaluation of weight loss, stools, and the use of antidiabetics and pancreatic enzyme was repeated.ResultsPatient characteristics were comparable in both groups. There were no differences in median blood loss, duration of operation, and hospital stay. No significant difference was noted in postoperative complications, mortality, and exocrine insufficiency. The incidence of diabetes mellitus was significantly higher in patients with duct occlusion.ConclusionsDuct occlusion without pancreaticojejunostomy does not reduce postoperative complications but significantly increases the risk of endocrine pancreatic insufficiency after duct occlusion.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo evaluate the incidence of posttransplant lymphoproliferative disease (PTLD) and the risk factors and the impact of this complication on survival outcomes in a large cohort of liver transplant recipients at a single institution.Summary Background DataLiver transplantation has been accepted as a therapeutic option for patients with end-stage liver disease since 1983, in large part due to the availability and reliance on the use of nonspecifically directed immunosuppression. However, as predicted and subsequently verified in 1968, an increased incidence of certain de novo malignancies has been observed, particularly with regards to lymphoid neoplasms. While many reports have confirmed and clarified the nature of PTLD, the literature is fraught with conflicting experience and outcomes with PTLD.MethodsFour thousand consecutive patients who underwent liver transplants between February 1981 and April 1998 were included in this analysis and were followed to November 2001. The effect of recipient age at the time of transplant, recipient gender, diagnosis, baseline immunosuppression, grading of PTLD, and association with Epstein-Barr virus were compared. The causes of death were also examined. Treatment for PTLD varied over the 20-year period, but all included massive reduction or elimination of baseline immunosuppression.ResultsThe 1-year patient survival for liver transplant patients with PTLD was 85%, while the overall patient survival for the entire cohort was 53%. The actuarial 20-year survival was estimated at 45%. The overall median time to PTLD presentation was 10 months, and children had an incidence of PTLD that was threefold higher than adults. Patient survival was better in children, in patients transplanted in the era of tacrolimus immunosuppression, in patients with polymorphic PTLD, and in those with limited disease. Interestingly, neither the presence or absence of Epstein-Barr virus nor the timing of PTLD presentation appeared to influence overall patient survival. Patients transplanted for alcohol-related liver disease had a similar incidence of PTLD but had a higher risk of mortality.ConclusionsWhile PTLD continues to pose problems in patients receiving liver transplants, improvements in patient survival have been observed over time. While it is too early to assess the impact of new advances in prophylaxis, diagnosis, and treatment, such approaches are based on an increased knowledge of the pathophysiology of PTLD.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo determine whether adjuvant postoperative active specific immunotherapy with a therapeutic polyvalent vaccine (PV) called Canvaxin can prolong survival following complete resection of melanoma metastatic to regional nodes (American Joint Committee on Cancer [AJCC] stage III melanoma).Summary Background DataDespite complete lymphadenectomy, 5-year overall survival (OS) for patients with melanoma metastatic to regional lymph nodes is only 20% to 50%, depending on the number of tumor-involved nodes. In 1984, the authors began phase II trials of Canvaxin PV as postsurgical adjuvant therapy for AJCC stage III melanoma.MethodsPatients who received PV between 1984 and 1998 were compared with patients who did not receive PV postsurgical therapy between 1971 and 1998. The seven covariates recently defined by the AJCC Melanoma Staging Committee (number of metastatic nodes, palpable status, ulceration, age, primary site, pT stage, and gender) were included by Cox regression in a multivariate model of OS. A computerized program matched PV and non-PV patients by these covariates.ResultsOf 2,602 patients who underwent complete lymphadenectomy for AJCC stage III melanoma with regional nodal metastases and were followed up by the same team of oncologists between 1971 and 1998, 935 received PV and 1,667 did not. Median OS and 5-year OS were significantly higher in PV than non-PV patients (56.4 vs. 31.9 months and 49% vs. 37%, respectively;P= .0001). When the non-PV patients were matched by the four most significant covariates, 447 matched pairs were formed between patients seen before or after January 1, 1985, and the OS was not different between the two time periods (P= .789). However, when the PV patients were matched with non-PV patients by six covariates forming 739 pairs, the PV patients survived longer (P= .0001). Detailed analysis of the 1,505 patients who were seen or who began vaccine therapy within 4 months after lymphadenectomy, and who had more complete data on the seven prognostic covariates showed that median OS and 5-year OS were higher in 445 PV patients than in 1,060 non-PV patients: 70.4 versus 31 months and 52% versus 37%, respectively (P= .0001). Multivariate Cox regression analysis identified six significant prognostic factors: number of metastatic nodes, size of metastatic nodes, pT stage, ulceration, age, and PV therapy. PV therapy reduced the relative risk of death to 0.64 (95% confidence interval, 0.55–0.76) (P= .0001); sex and site of primary were of borderline significance.ConclusionsThis large single-institution study independently confirmed the significance of prognostic covariates in the new AJCC staging system. By using modern statistical methods that controlled for all known prognostic factors, it also demonstrated PV’s ability to significantly enhance OS. A multicenter phase III randomized trial is underway to validate the efficacy of PV as a postsurgical adjuvant.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo determine whether propranolol and growth hormone (GH) have additive effects to combat burn-induced catabolism.Summary Background DataBoth GH and propranolol have been attributed anabolic properties after severe trauma and burn. It is conceivable that the two in combination would have additive effects.MethodsFifty-six children with more than 40% TBSA burns were randomized to one of four anabolic regimens: untreated control, GH treatment, propranolol treatment, or combination GH plus propranolol therapy. Clinical treatment was identical for all groups. Resting energy expenditure was determined by indirect calorimetry and skeletal muscle protein kinetics were measured using stable amino acid isotope infusions before and after each anabolic regimen.ResultsThere were no differences in age, sex, or burn size between groups. Tachycardia and energy expenditure were decreased during propranolol treatment (P< .05). The net balance of muscle protein synthesis and breakdown was improved during proprandol and GH plus propranolol treatment (P< .05). There was no significant benefit of GH alone. No additive effect of combination therapy was seen.ConclusionsPropranolol is a strongly anabolic drug during the early, hypercatabolic period after burn. No synergistic effect between propranolol and GH was identified.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment.Summary Background DataThe use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study.MethodsSixteen surgical residents (PGY 1–4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessmentr> 0.80).ResultsNo differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P< .007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27,P< .04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case;P< .008, Mann-Whitney test).ConclusionsThe use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo present the authors’ 30-year experience with traumatic aortic rupture (TAR).Summary Background DataTAR is a highly lethal injury. Most institutions manage a small number of cases, and most surgeons receive only modest exposure during training.MethodsBetween 1971 and 2001, the authors operated on 219 patients with a diagnosis of TAR. Diagnosis of TAR since 1994 has been based exclusively on the use of contrast-enhanced spiral computed tomography, with angiography reserved for equivocal cases (periaortic mediastinal hematoma without aortic wall abnormalities). Patients were divided according to surgical technique. Eighty-two patients (group A) were operated on with a clamp-and-sew technique. Sixty-four patients (group B) underwent surgery with the use of a passive shunt, and 73 patients (group C) were treated using heparin-less partial cardiopulmonary bypass.ResultsMortality was 18 patients for group A (21.9%), 23 patients for group B (35.9%), and 13 patients for group C (17.8%) (P= .03). Paraplegia occurred in 15 of 64 survivors in group A (23.4%), 7 of 41 survivors in group B (17%), and 0 of 60 survivors in group C (P= .0005). Aortic occlusion without lower body perfusion for longer than 30 minutes (P= .004) and surgical technique without lower body bypass support (P= .0005) were associated with paraplegia.ConclusionsSurgery for TAR based on spiral computed tomography screening and diagnosis is reliable. The use of heparin-less distal cardiopulmonary bypass in the authors’ hands is safe and is associated with a reduced incidence of paraplegia.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveTo review perioperative results and late survival after thoracoabdominal aneurysm repair (TAA), in particular to assess the impact over time of epidural cooling (EC) on spinal cord ischemic complications (SCI).Summary Background DataA variety of operative approaches and protective adjuncts have been used in TAA to minimize the major complications of perioperative death and SCI. There is no consensus with respect to the optimal approach.MethodsFrom January 1987 to November 2001, 337 consecutive TAA repairs were performed by a single surgeon. Clinical features included prior aortic grafts in 97 (28.8%) and emergent operation in 82 (24.6%), including rupture in 46 (13.6%) and dissection in 63 (19%). Operative management consisted of a clamp/sew technique with adjuncts in 93%. EC (since July 1993) to prevent SCI was used in 194 (57.6%) repairs. Variables associated with the end points of operative mortality and postoperative SCI were assessed with the Fisher exact test and logistic regression; late survival was estimated with the Kaplan-Meier method.ResultsOperative mortality was 8.3% and was associated with nonelective operation, intraoperative hypotension, total transfusion requirement, and the postoperative complications of paraplegia, renal failure, and pulmonary insufficiency. Postoperative renal failure and transfusion requirement were independent correlates of mortality. SCI of any severity occurred in 38 of 334 (11.4%) operative survivors, with 22/38 (6.6% of cohort) sustaining total paraplegia. EC reduced the risk of SCI in patients with types I–III TAA (10.6% vs. 19.8%,P= .04). Independent correlates of SCI over the entire study interval included types I/II TAA, rupture, cross-clamp duration, sacrifice of T9–L1 intercostal vessels, and intraoperative hypotension. Late survival rates at 2 and 5 years were 81.2 ± 3% and 67.2 ± 5%.ConclusionsEC has decreased the risk of SCI after TAA repair. Decreasing the substantial proportion (nearly 25%) of patients requiring nonelective operation will improve results. Late survival is equal to that after routine AAA repair, indicating that the considerable resource expenditure required for TAA repair is worthwhile.

ISSN:0003-4932    

出版商:OVID    

年代:2002

数据来源: OVID