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Prospective Database (prospective + database)
Selected AbstractsSingle-Institution Experience in the Management of Patients with Clinical Stage I and II Cutaneous Melanoma: Results of Sentinel Lymph Node Biopsy in 240 CasesDERMATOLOGIC SURGERY, Issue 11 2005Jordi Rex MD Background. Lymphatic mapping and sentinel lymph node biopsy (SLNB) has been developed as a minimally invasive technique to determine the pathologic status of regional lymph nodes in patients without clinically palpable disease and incorporated in the latest version of the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma. Objective. To analyze the results of SLNB and the prognostic value of the micrometastases and the pattern of early recurrences in patients according to sentinel lymph node (SLN) status. Method. Patients with cutaneous melanoma in stages I and II (AJCC 2002) who underwent lymphatic mapping and SLNB from 1997 to 2003 were included in a prospective database for analysis. Results. The rate of identification of the SLN was 100%. Micrometastases to SLN were found in 20.8% of patients. The rate of SLN micrometastases increased according to Breslow thickness and clinical stage. Breslow thickness of 0.99 mm was the optimal cutpoint for predicting the SLNB result. Twenty-four patients (12.3%) developed a locoregional or distant recurrence at a median follow-up of 31 months. Recurrences were more frequent in patients with a positive SLN. Among patients who had a recurrence, those with a positive SLN were more likely to have distant metastases than those with negative SLN. Nodal recurrences were more frequent in patients with a negative SLN compared with those with a positive SLN. Conclusions. The status of the SLN provides accurate staging for identifying patients who may benefit from further therapy and is the most important prognostic factor of relapse-free survival. THIS WORK WAS SUPPORTED BY GRANTS FROM FONDO DE INVESTIGACIONES SANITARIAS (98/0449), BECA DE FORMACIÓ DE PERSONAL INVESTIGADOR (2001/FI0757), AND THE RED ESPÑOLA DE CENTROS DE GENÓMICA DEL CÁNCER (C03/10). [source] The Accuracy and Completeness of Data Collected by Prospective and Retrospective MethodsACADEMIC EMERGENCY MEDICINE, Issue 9 2005J. Tobias Nagurney MD Abstract Objectives: To describe and test a model that compares the accuracy of data gathered prospectively versus retrospectively among adult emergency department patients admitted with chest pain. Methods: The authors developed a model of information flow from subject to medical record to the clinical study case report form, based on a literature review. To test this model, a bidirectional (prospective and retrospective) study was conducted, enrolling all eligible adult patients who were admitted with a chief complaint of chest pain. The authors interviewed patients in the emergency department to determine their chest pain history and established a prospective database; this was considered the criterion standard. Then, patient medical records were reviewed to determine the accuracy and completeness of the information available through a retrospective medical record review. Results: The model described applies the concepts of reliability and validity to information passed on by the study subject, the clinician, and the medical record abstractor. This study was comprised of 104 subjects, of which 63% were men and the median age was 63 years. Subjects were uncertain of responses for 0,8% of questions and responded differently upon reinterview for subsets of questions 0,30% of the time. The sensitivity of the medical record for risk factors for coronary artery disease was 0.77 to 0.93. Among the 88 subjects (85%) who indicated that their chest pain was substernal or left chest, the medical record described this location in 44%. Timing of the chest pain was the most difficult item to accurately capture from the medical record. Conclusions: Information obtained retrospectively from the abstraction of medical records is measurably less accurate than information obtained prospectively from research subjects. For certain items, more than half of the information is not available. This loss of information is related to the data types included in the study and by the assumptions that a researcher performing a retrospective study makes about implied versus explicitly stated responses. A model of information flow that incorporates the concepts of reliability and validity can be used to measure some of the loss of information that occurs at each step along the way from subject to clinician to medical record abstractor. [source] Risk factors and characteristics of extent progression in ulcerative colitisINFLAMMATORY BOWEL DISEASES, Issue 9 2009María Josefina Etchevers MD Abstract Background: The main objective was to identify risk factors for extent progression in distal ulcerative colitis. The secondary objective was to determine clinical characteristics of disease at the time of progression. Methods: Data were obtained from a prospective database. Distal colitis was defined as disease limited to rectum and sigmoid colon (n = 178), extensive colitis as involvement of at least the descending colon (n = 179), and colitis with progression when there was a change of category from distal to extensive (n = 63). To study clinical characteristics at the time of progression, a nested case,control study was performed. Results: Compared to distal colitis, colitis with progression was associated to significantly higher prevalence of extraintestinal manifestations (42.9% versus 15.5%) steroid-refractory course (28.0% versus 2.2%), requirement of thiopurines (44.3% versus 17.3%), cyclosporine (25.4% versus 1.9%), infliximab (9.5% versus 1.2%), surgery (20.6% versus 0.6%), and incidence of neoplasia (6.3% versus 0%). However, these differences appeared after disease progression. Regression analysis demonstrated that preexisting independent predictive factors for progression were younger age at diagnosis (hazard ratio [HR] 0.979 95% confidence interval [CI] 0.959,0.999) and presence of sclerosing cholangitis (HR 12.83, 95% CI 1.36,121.10). The nested case,control study showed that at the time of progression the flare was more severe in cases than in matched controls, with significant differences in markers of disease severity, therapeutic requirements, hospitalizations, and surgery. Conclusions: Patients with distal ulcerative colitis diagnosed at a younger age or with associated sclerosing cholangitis are at higher risk for progression. Disease flare associated with progression follows a severe course with high therapeutic requirements. (Inflamm Bowel Dis 2009) [source] Preoperative determinants of common bile duct stones during laparoscopic cholecystectomyINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 11 2008A. J. Sheen Summary Introduction:, The aim of this study is to determine whether there are any clinical or biochemical predictors of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. Methods:, A prospective database of nearly 1000 laparoscopic cholecystectomies performed under the care of a single surgeon with a standardised technique between 1999 and 2006, was analysed. Clinical presentation, ultrasound and immediate preoperative biochemical results as well as the operative cholangiogram findings were reviewed. Routine cholangiography was attempted in most patients and the primary outcome variable was the detection of bile duct stones. The data was analysed using chi-squared test for categorical variables. The significant variables on univariate analysis were further characterised to identify the independent predictors of bile duct stones using a logistic regression model (significance p < 0.05). Results:, A total of 757 of 988 patients (77%) underwent cholangiography. Male-to-female ratio was 1 : 3 with a median age of 54 years (range: 17,93). Ten per cent of patients had bile duct stones identified on cholangiography. On univariate analysis, jaundice (p = 0.019), cholangitis (p < 0.001), alanine transaminase > 100 (p = 0.024), alkaline phosphatase (ALP) > 350 (p < 0.001) and CBD > 10 mm (p = 0.01) were significant markers for predicting bile duct stones. Bilirubin > 30 (×2 normal) was found not to be significant (p = 0.145). On a logistic regression model, ALP > 350 and/or cholangitis were found to be independent predictive factors of CBD stones (odds ratio 6.1). Conclusions:, If a policy of routine intra-operative cholangiography is not adopted, a history of cholangitis or a raised ALP immediately preoperatively should lead to a high suspicion of CBD stones. [source] Meeting the 12 lymph node (LN) benchmark in colon cancer,JOURNAL OF SURGICAL ONCOLOGY, Issue 1 2010A. Rajput MD Abstract Background Examining ,12 LN in colon cancer has been suggested as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN centers compared to a US population-based sample. Methods Patients with stage I,III disease resected at NCCN centers were identified from a prospective database (n,=,718) and were compared to 12,845 stage I,III patients diagnosed in a SEER region. Age, gender, location, stage, number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Multivariate logistic regression models were developed to identify factors associated with evaluating 12 LNs. Results 92% of NCCN and 58% of SEER patients had ,12 LN evaluated. For patients treated at NCCN centers, factors associated with not meeting the 12 LN target were left-sided tumors, stage I disease and BMI >30. Conclusions ,12 LN are almost always evaluated in NCCN patients. In contrast, this target is achieved in 58% of SEER patients. With longer follow-up of the NCCN cohort we will be able to link this quality metric to patterns of recurrence and survival and thereby better understand whether increasing the number of nodes evaluated is a priority for cancer control. J. Surg. Oncol. 2010;102:3,9. © 2010 Wiley-Liss, Inc. [source] Intra-abdominal metastases from soft tissue sarcomaJOURNAL OF SURGICAL ONCOLOGY, Issue 3 2004FRCS (Ed.), FRCS (Glas.), Kasim A. Behranwala MS Abstract Objective To define the clinical features and prognosis of patients with abdominal metastasis from primary soft tissue sarcoma (STS) at other sites. Methods All patients with abdominal metastasis from STS were identified from the Royal Marsden Hospital Sarcoma Unit prospective database from January 1990 to July 2001. Results Nineteen patients developed abdominal metastasis out of a cohort of 2127 patients (0.9%) evaluated during the study interval. The median age was 49 (19,71) years. The median time to abdominal metastasis from diagnosis of the primary was 27 (8,91) months. The presenting complaints were incomplete intestinal obstruction (n,=,5), abdominal pain (n,=,4), mass (n,=,2), gastrointestinal bleed (n,=,2), urinary obstruction (n,=,2), anorexia (n,=,1), and abdominal distension (n,=,1). Emergency laparotomy was done for perforative peritonitis (n,=,2), intussusception (n,=,2), and bleed in spleen (n,=,1). Two patients were asymptomatic. The common histologies were myxoid liposarcoma (n,=,6) and leiomyosarcoma (n,=,4). The median follow-up of survivors post metastasis was 12 months. Abdominal metastatectomy was performed in 16 patients, 3 of these patients had abdominal recurrences. The 1- and 2-year overall disease specific survival for the 19 patients was 66% (SE,=,11%) and 43% (SE,=,13%) with a median survival of 13 months (95% CI,=,11.8,14.7). Metastasectomy was associated with slight improved median post-metastasis survival (33 months vs. 8 months for unresected patients). Conclusions Although abdominal metastasis is rare, vigilance is warranted. Symptomatic patients should be examined and investigated thoroughly for metastases. Surgery is the treatment of choice for patients with an acute presentation; however, survival is dismal. J. Surg. Oncol. 2004;87:116,120. © 2004 Wiley-Liss, Inc. [source] Clinical relevance of parasternal uptake in sentinel node procedure for breast cancerJOURNAL OF SURGICAL ONCOLOGY, Issue 1 2004Hans F.J. Fabry MD Abstract Background and Objectives Preoperative lymphoscintigraphy contributes highly to the accuracy of the sentinel node procedure. Besides routing towards the axilla, in a number of patients additional parasternal focal accumulation may be observed. So far the clinical consequences of this parasternal uptake remains unclarified, i.e., whether any internal mammary lymph node uptake should be surgically biopsied. An analysis of all sentinel node procedures with parasternal uptake was performed. Methods Sixty-nine patients with scintigraphic parasternal uptake and with a minimal follow-up of 24 months, were selected from a prospective database. Tumor characteristics, treatment strategies, and recurrences of these patients were analyzed and subsequently matched against the present day indications for adjuvant treatment. Results During follow-up (median 41 months) only four (6%) patients developed systemic disease. Initially, three of these patients did not receive adjuvant chemotherapy. Two are alive without evidence of disease after treatment of these recurrences. Currently these patients would, initially, all have been eligible for chemotherapy based on tumor characteristics and age according to international guidelines. Conclusions For the indication of adjuvant treatment, the status of the internal mammary lymph nodes was not relevant in our patients. Parasternal uptake is not an indication to extend the surgical procedure. J. Surg. Oncol. 2004;87:13,18. © 2004 Wiley-Liss, Inc. [source] Third look surgery and beyond for appendiceal malignancy with peritoneal disseminationJOURNAL OF SURGICAL ONCOLOGY, Issue 1 2003Faheez Mohamed MBChB, MRCS Abstract Background and Objectives Second look surgery has been previously studied in patients with recurrent peritoneal dissemination from appendiceal malignancy. However, selection criteria for third, fourth, and subsequent reoperations are not available. Methods Five hundred and one patients with epithelial peritoneal surface malignancy of appendiceal origin underwent treatment with cytoreductive surgery and intraperitoneal chemotherapy during an 18-year period. Forty-five of these patients (8.9%) underwent three or more operative interventions. A critical statistical analysis of the impact of selected clinical features on survival was performed from a prospective database. Results Overall 5-year survival of these 45 patients was 70%. Five- and ten-year survival rates for patients with three interventions were 60 and 48%, for four interventions were 78 and 36%, and for five or more interventions were 100 and 80%. Sites of recurrent disease, histopathologic type of tumor, and lymph node status had no impact on survival. A complete second and third cytoreduction was associated with an improved 5-year survival rate. Conclusions Prolonged survival in patients with three or more reoperations was significantly associated with a complete cytoreduction. However, after four or more interventions, the effects of tumor biology may predominate. Although 5-year survival is likely with multiple reoperations, prolonged follow-up shows that cancer cure is a rare event. J. Surg. Oncol. 2003;83:5,13. © 2003 Wiley-Liss, Inc. [source] The completely dry rate: A critical re-evaluation of the outcomes of slingsNEUROUROLOGY AND URODYNAMICS, Issue 7 2005Kathleen C. Kobashi Abstract Objective To critically evaluate sling outcomes and revisit the realistic goals of anti-incontinence surgery. Materials and Methods A review of an Institutional Review Board-approved prospective database revealed the outcomes of four different sling techniques that are utilized at our institution. Results Four hundred ninety-eight patients had a mean follow-up varying from 9 to 24 months (range 6,50) after undergoing one of four different sling techniques utilized at our institution. The techniques had similar results with regard to completely dry rate, overall success rate, and rate of urgency regardless of the variation in follow-up time. Success was defined as completely dry or leakage =,1/week or =,70% improved by questionnaire in those patients who leaked 1/week. Success, by this definition, varied from 74.9% to 85.7%, but the completely dry rate varied from 36.1% to 45.2%. An additional 31.0% to 33.3% leaked =,1/week, and of the remaining patients, 24.5% to 44.4% considered themselves =,70% improved despite leakage >,1/week. Urge incontinence was reported by 24.4% to 33.3% of patients. Conclusion As surgeons, we must constantly reevaluate the outcomes and purposes of the procedures we perform on our patients. © 2005 Wiley-Liss, Inc. [source] Training in cordocentesis: the first 50 case experience with and without a cordocentesis training modelPRENATAL DIAGNOSIS, Issue 5 2010Fuanglada Tongprasert Abstract Objective To compare the outcomes of the first 50 cordocenteses at mid-gestation performed by operators who either or not received training on an in vitro model earlier. Materials and Methods Our unit keeps a prospective database on procedure details and outcomes of cordocenteses. We compared 50 consecutive procedures, from the first one onwards, performed by 5 specialists early in their maternal fetal medicine (MFM) practice, either systematically trained (study group) or not (control group) on an in vitro cordocentesis training model (n = 500 procedures). This training was introduced at the time point MFM became a formal subspeciality in Thailand. Multiple pregnancies and fetuses with chromosomal or structural abnormalities were excluded. The main outcome measures included mean duration of the procedure, the success and fetal loss rate. Results The average duration in the control group was significantly longer than that in the study group (13.2 vs 6.4 min, p < 0.001). Conversely, the success rate was significantly lower (94.8 vs 98.8%, p = 0.011). There were no differences in fetal loss rate. Conclusion Systematic training on a cordocentesis model reduces the time required to successfully obtain a fetal cord blood sample. Copyright © 2010 John Wiley & Sons, Ltd. [source] Etiology of Late Free Flap Failures Occurring After Hospital Discharge,THE LARYNGOSCOPE, Issue 11 2007Mark K. Wax MD Abstract Objectives: Vascular compromise of free flaps most commonly occurs in the immediate postoperative period in association with failure of the microvascular anastomosis. Rarely do flaps fail in the late postoperative period. It is not well understood why free flaps can fail after 7 postoperative days. We undertook a case review series to assess possible causes of late free flap failure. Study Design: Retrospective review at two tertiary referral centers: Oregon Health Sciences University and University of Alabama at Birmingham. Methods: A review of 1,530 flaps performed in 1,592 patients between 1998 and 2006 were evaluated to identify late flap failure. Late flap failure was defined as failure occurring after postoperative day 7 or on follow-up visits after hospital discharge. A prospective database with the following variables was examined: age, medical comorbidities, postreconstructive complications (fistula or infection), hematoma, seroma, previous surgery, radiation therapy, intraoperative findings at the time of debridement, nutrition, and, possibly, etiologies. Results: A total of 13 patients with late graft failure were identified in this study population of 1,530 (less than 1%) flaps; 6 radial forearm fasciocutaneous flaps, 2 rectus abdominis myocutaneous flaps, 4 fibular flaps, and 1 latissimus dorsi myocutaneous flap underwent late failure. The time to necrosis was a median of 21 (range, 7,90) days. Etiology was believed to possibly be pressure on the pedicle in the postoperative period in four patients (no sign of local wound issues at the pedicle), infection (abscess formation) in three patients, and regrowth of residual tumor in six patients. Loss occurring within 1 month was more common in radial forearm flaps and was presented in the context of a normal appearing wound at the anastomotic site, as opposed to loss occurring after 1 month, which happened more commonly in fibula flaps secondary to recurrence. Conclusion: Although late free flap failure is rare, local factors such as infection and possibly pressure on the pedicle can be contributing factors. Patients presenting with late flap failure should be evaluated for residual tumor growth. [source] Algorithm for Reconstruction After Endoscopic Pituitary and Skull Base Surgery,THE LARYNGOSCOPE, Issue 7 2007Abtin Tabaee MD Abstract Introduction: The expanding role of endoscopic skull base surgery necessitates a thorough understanding of the indications, techniques, and limitations of the various approaches to reconstruction. The technique and outcomes of endoscopic skull base reconstruction remain incompletely described in the literature. Study Design and Methods: Patients undergoing endoscopic skull base surgery underwent an algorithmic approach to reconstruction based on tumor location, defect size, and presence of intraoperative cerebrospinal fluid (CSF) leak. A prospective database was reviewed to determine the overall efficacy of reconstruction and to identify risk factors for postoperative CSF leak. Results: The diagnosis in the 127 patients in this series included pituitary tumor in 70 (55%) patients, encephalocele in 16 (12.6%) patients, meningioma in 11 (8.7%) patients, craniopharyngioma in 9 (7.1%) patients, and chordoma in 6 (4.7%) patients. Successful reconstruction was initially achieved in 91.3% of patients. Eleven (8.7%) patients experienced postoperative CSF leak, 10 of which resolved with lumbar drainage alone. One (0.8%) patient required revision surgery. Correlation between postoperative CSF leak and study variables revealed a statistically significant longer duration of surgery (243 vs. 178 min, P = .008) and hospitalization (12.1 vs. 4.5 days, P < .0001) and a trend toward larger tumors (mean, 3.2 vs. 2.3 cm; P = .058) in patients experiencing postoperative CSF leak. Conclusion: The algorithm for reconstruction after endoscopic surgery presented in this study is associated with excellent overall efficacy. A greater understanding of risk factors for postoperative CSF leak is imperative to achieve optimal results. [source] Laparoscopic revision of gastric band surgeryANZ JOURNAL OF SURGERY, Issue 5 2010Stephanie Bardsley Abstract Aim:, To identify the outcome of laparoscopic revision of gastric band surgery with respect to percentage of excess weight lost (%EWL). Methods:, Analysis of a prospective database was then performed and %EWL was plotted with respect to time from initial procedure and also time from revision procedure. Results:, All revision operations were performed laparoscopically. There were no patient deaths, but two serious complications. Percentage excess weight loss after replacement of the band because of prosthetic failure or dysphagia was 57% at an average follow-up of 19 months. For repositioning of the band due to slippage, the %EWL was 72% at an average of 15 months follow-up for those who had the existing band repositioned, and 42% at an average of 23 months follow-up for those who had a new band repositioned. Conclusion:, Revision laparoscopic gastric band surgery is a safe option for patients, and results in good %EWL at an average follow-up period of 19 months. [source] Use of inferior vena cava filters in a tertiary referral centre in AustraliaANZ JOURNAL OF SURGERY, Issue 5 2010Alok Tiwari Abstract Introduction:, To investigate the use of inferior vena cava (IVC) filters in a tertiary referral centre, looking at indication, types of filters and, with temporary/optional filters, removal rates. Methods:, Data was collected from a prospective database of all IVC filters inserted from January 2003 to January 2007. Patients' records and radiological imaging were all reviewed. Results:, 66 patients (40 males) had IVC filters inserted during the study period. The median age of the male patients was 57.5 (21,79) years, and females 56 (24,81). There were 49 (74.2%) temporary/optional filters and 17 (25.8%) permanent filters. The most common indication for filter was a contraindication to anticoagulation for both permanent (64.7%) and temporary/optional filters (77.6%). In the temporary/optional filter group, 38 of 49 (77.6%) patients had documented venous thromboembolism, while in the permanent filter group, this was 14 of 17 (82.4%). Of the optional filters, 22 of 49 (45.8%) have been removed. Conclusion:, More than half (54.2%) of temporary/optional filters were not removed and with potential for long-term complications. A protocol has now being instituted for vascular surgeons to authorize the insertion of filters and to then be responsible for ensuring their removal. [source] BT04 LAPAROSCOPIC REVISION OF GASTRIC BAND SURGERYANZ JOURNAL OF SURGERY, Issue 2009S. Bardsley Aim: , To identify the outcome of laparoscopic revision of gastric band surgery with respect to percentage of excess weight lost (%EWL). Methods: , Analysis of a prospective database was performed and %EWL was plotted with respect to time from initial procedure and also time from revision procedure. Results: , All revision operations were performed laparoscopically. There were no patient deaths, but two serious complications. Percentage Excess Weight Loss after replacement of the band because of prosthetic failure or dysphagia was 57% at an average follow up of 19 months. For repositioning of the band due to slippage, the %EWL was 72% at an average of 15 months follow up for those who had the existing band repositioned, and 42% at an average of 23 months follow up for those who had a new band repositioned. Conclusion: , Revision laparoscopic gastric band surgery is a safe option for patients, and results in good %EWL at an average follow up period of 19 months. [source] HP23 USE OF ANTI-REFLUX MEDICATION AFTER ANTI-REFLUX SURGERYANZ JOURNAL OF SURGERY, Issue 2007B. P. L. Wijnhoven Purpose It is thought that a substantial number of patients who undergo anti-reflux surgery use anti-reflux medication post operatively, despite no objective evidence of reflux. This study aims to determine the prevalence and underlying reasons for anti-reflux medication usage in patients after anti-reflux surgery. Methodology A questionnaire (13 questions) on the usage of anti-reflux medication was sent to 1016 patients from a prospective database of anti-reflux surgery patients. Results 852 patients (84%), (437 males & 415 females with a mean age 58 yrs) returned the questionnaire. Mean follow up was 5.9 yrs after surgery. A single or combination of medications was being taken by 319 patients (37%): 82% proton pump inhibitors, 9% H2-blockers and 34% antacids. 54 patients (18%) had never stopped taking medication, whereas 261 patients (82%) re-started medication at a mean of 2.4 yrs after surgery. Persistent or return of the same or different symptoms was the reason for taking medication by the vast majority (85%), whereas 15% were asymptomatic or had other reasons for medication use. A response of symptoms to the medication occurred for 30% of the patients, whereas 64% noticed some improvement. Postoperative 24-hour pH studies (while off medication) were abnormal in 17/62 patients (27%) on medication and in 5/73 patients (6%) not taking medication. Conclusions Anti-reflux medication is frequently taken by patients for symptoms after surgery, despite normal pH profiles in the majority. Strategies need to be employed to lower the inappropriate use of medications after surgery and to further evaluate the mechanisms underlying postoperative symptoms, which are non-responsive to anti-reflux medication. [source] MALIGNANT PROGRESSION OF ANAL INTRA-EPITHELIAL NEOPLASIAANZ JOURNAL OF SURGERY, Issue 8 2006Angus J. M. Watson Background: Anal intra-epithelial neoplasia (AIN) is believed to be a precursor to squamous cell carcinoma of the anus. The risk of developing anal cancer in patients with AIN, although known to occur, has been thought to be relatively low. This study reviews our experience with AIN, reviewing the incidence and risk factors for development of invasive malignancy and the outcome of present management strategies. Methods: This study examined a cohort of 72 patients identified from a prospective database with AIN from a single institution between January 1996 and December 2004. A single pathologist examined all pathological specimens. Results: There were 72 patients (52 women) and the median age was 49 years (range, 18,81 years). We identified progression of AIN to invasive malignancy in eight patients despite undergoing surveillance. Regression following treatment or biopsy was seen in 25 patients. Four patients required stomas for incontinence following treatment. Conclusion: This study has shown a high rate of progression to invasive malignancy (11%) with AIN despite surveillance. The patients at risk of developing squamous cell carcinoma were the immunocompromised and those with genital intra-epithelial field change. Treatment of AIN has significant complications and despite treatment, invasive cancers do occur. Decisions made for treatment of AIN can affect treatment choices if invasive malignancy develops. [source] Trends in the management of severe acute pancreatitis: interventions and outcomeANZ JOURNAL OF SURGERY, Issue 5 2004Richard Flint Background: Severe acute pancreatitis (SAP) in the intensive care unit (ICU) is a complex and challenging problem. The aim of the present study was to identify trends in management of SAP patients admitted to a tertiary level ICU, and to relate these to changes in interventions and outcome. Methods: Patients admitted to the Department of Critical Care Medicine (DCCM), Auckland Public Hospital with SAP from 1988 to 2001 (inclusive) were identified from the DCCM prospective database, and data were extracted from several sources. Results: One hundred and twelve patients (men 69, women 43, mean age (±SD) 57.3 years ± 14.3) were admitted with SAP to DCCM in the 13-year period. Aetiology was gallstones (42%), alcohol (29%), or idiopathic (29%). At admission to DCCM the median duration of symptoms was 7 days (range 1,100) and the mean (±SD) Acute Physiology and Chronic Health Evaluation II score was 19.9 ± 8.2. Ninety-nine patients (88%) had respiratory failure and 79 (71%) had circulatory failure. The number of necrosectomies peaked between 1991 and 1995 (17/35 patients (49%) compared to 4/22 (18%) prior 1991; ,2 = 6.90, P = 0.032). Abdominal decompression, enteral nutrition, percutaneous tracheostomy, and the use of stents in endoscopic retrograde cholangiopancreatography were introduced over the study period. The length of stay in DCCM did not alter (median 4 days, range 1,60) but there was a reduction in the length of hospital stay (median 36 days to 15 days; anova= 6.16, P = 0.046). The overall mortality was 31% (35/112) and did not alter over the study period. Conclusions: SAP remains a formidable disease with a high mortality despite a number of changes in intensive care and surgical management. [source] Implication of intraoperative sentinel node imprint cytology for consent in the SNAC trialANZ JOURNAL OF SURGERY, Issue 3 2004Melissa A. Bochner Background: Women randomized into the sentinel node biopsy-only arm of the Sentinel Node versus Axillary Clearance Trial require axillary clearance if the sentinel node is unable to be identified, or if the sentinel node contains metastases. The aim of the present study was to determine the likelihood of immediate and delayed axillary clearance in patients in the trial when nodes were subjected to intraoperative imprint cytology. Methods: A prospective database for 400 patients with operable breast cancer was analysed to determine the likelihood of lymph node involvement according to tumour size. The ability to successfully remove a sentinel node and the accuracy of intraoperative imprint cytology of sentinel nodes was investigated. These data were used to predict the likelihood of patients proceeding to immediate or delayed axillary clearance. Results: The rate of lymph node involvement was 0%, 10%, 30%, and 53% in tumours measuring <5 mm, 6,10 mm, 11,20 mm and 21,30 mm, respectively. A sentinel node was identified in 95% of cases. In a series of 79 consecutive cases using intraoperative imprint cytology, 37% of sentinel nodes containing metastases were identified intraoperatively. The estimated likelihood of undergoing immediate axillary clearance therefore ranges from 5% for tumours <5 mm, up to 24% for tumours 21,30 mm. Similarly the likelihood of delayed clearance ranges from 0% to 32% depending on tumour size. Conclusions: It is possible to give detailed and accurate information to patients undergoing sentinel node biopsy about both the risk of lymph node involvement and the likelihood of requiring immediate or secondary axillary clearance. [source] Epidemiology of abdominal aortic aneurysm in an Asian populationANZ JOURNAL OF SURGERY, Issue 6 2003Ming Kon Yii Background: Abdominal aortic aneurysms (AAA) are common in the Caucasian population. Apart from reported differences in the occurrence of AAA in the black and white populations, there are few studies on the incidence of AAA in the Asian population. Methods: A prospective database of all patients with AAA seen between 1996 and 1999, in the South-East Asian state of Sarawak in Borneo Island, was analysed. The demographic data included patient's age, sex, ethnic group, date of diagnosis, comorbidities, presentations and treatment outcomes. These were compared with the state population's demographic statistics. Results: Diagnoses of AAA were made in 123 patients during the study period. The male to female ratio was 3.5 : 1. The age range was 39,88 years with a median age of 70 years. Four patients were younger than 55 years. The incidence rate for the at-risk male population older than 50 years was 25.6/100 000. The incidence rate reached 78.3/100 000 for males older than 70 years. The incidence rate for females older than 50 years was 7.6/100 000 and for those older than 70 years it was 18.7/100 000. All races were affected. Smoking, hypertension or respiratory disorders were present in more than 40% of the patients. Half of the patients underwent surgical repair. Conclusion: This study shows that AAA in this Asian population is not uncommon and the incidence is comparable to the Western world. [source] Comparative outcomes of elderly patients undergoing Altemeier procedure versus laparoscopic rectopexy for rectal prolapseASIAN JOURNAL OF ENDOSCOPIC SURGERY, Issue 1 2010O. De Oliveira Jr Abstract Introduction: We compared outcomes of elderly patients (>70 years) who underwent the Altemeier procedure versus laparoscopic rectopexy for full-thickness rectal prolapse. Materials and Methods: We reviewed our data from a prospective database and the medical records of patients treated at a single institution from 2002 to 2008. Patients who underwent surgery for full-thickness rectal prolapse were evaluated. Results: Sixteen patients underwent laparoscopic rectopexy (median age 82 years; ASA 2.6), and 16 patients underwent the Altemeier procedure (median age 85 years; ASA 2.8). The Altemeier procedure patients had a significantly higher recurrence rate when compared to laparoscopic rectopexy patients (P<0.045). The mean length of follow-up was longer for the Altemeier group (20 months) compared to the laparoscopic rectopexy group (28.5 months; most recurrence (5/6) occurred <1 year. The median length of specimen removed in the Altmeier group was 9.5 cm (6.5,18.5 cm). The majority of patients in both groups had preoperative fecal incontinence. Significantly more Altemeier patients reported worsening perioperative fecal incontinence at 1,3 months (p<0.046). All laparoscopic rectopexy patients underwent general anesthesia while 44% of the Altemeier patients underwent regional anesthesia (p<0.003). One laparoscopic rectopexy patient required reoperation for an incarcerated trocar site hernia. No other major complications occurred in either group. There was no difference in rates of minor complications. Discussion: Compared to the Altemeier procedure, laparoscopic rectopexy for elderly patients with rectal prolapse resulted in a significantly smaller recurrence rate, better perioperative fecal incontinence and an equivalent morbidity rate. [source] The St. George Homebirth Program: An evaluation of the first 100 booked womenAUSTRALIAN AND NEW ZEALAND JOURNAL OF OBSTETRICS AND GYNAECOLOGY, Issue 6 2009Jane McMURTRIE Background:, The St. George Homebirth Program was the first publicly funded homebirth model of care set up in New South Wales. This program provides access to selected women at low obstetric risk the option of having their babies at home. There are only four other publicly funded homebirth programs operating in Australia. Aims:, To report the outcomes of the first 100 women booked at the St. George Homebirth Program. Methods:, A prospective descriptive study was undertaken. Data were collected on the first 100 women who gave birth between November 2005 and March 2009. Two databases were accessed and missing data were followed up by review of the relevant charts. Results:, Of the first 100 booked women, 63 achieved a homebirth, 30 were transferred to hospital or independent midwifery care in the antenatal period and seven were transferred intrapartum. Two women were transferred to hospital in the early postnatal period, one for a postpartum haemorrhage and one for hypotension. One baby suffered mild respiratory distress, was treated in the emergency department and was discharged home within four hours. Conclusion:, The St. George Hospital homebirth program has provided reassuring outcomes for the first 100 women it has cared for over the past four years. Wider availability of this service could be achieved provided there is the appropriate close collaboration between providers and effective processes for consultation, referral and transfer. The outcomes of women and babies in publicly funded homebirth programs deserve further study, and the development of a national prospective database of all planned homebirths would contribute to this knowledge. [source] Maternal complications and pregnancy outcome in women with mechanical prosthetic heart valves treated with enoxaparinBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 12 2009C McLintock Objective, To determine maternal and fetal outcomes in women with mechanical heart valves managed with therapeutic dose enoxaparin during pregnancy. Design, Retrospective audit. Setting, Hospital-based high-risk antenatal clinics. Population, Pregnant women with mechanical heart valves attending high-risk antenatal clinics, treated with enoxaparin (1 mg/kg twice daily) during pregnancy. Methods, Women with mechanical heart valves treated with enoxaparin at any stage during pregnancy (1997,2008) identified using a database of women with mechanical heart valves attending the high-risk clinics and a prospective database of women prescribed enoxaparin for any indication during pregnancy. Main outcome measures, Maternal outcomes included thromboembolic and haemorrhagic complications. Pregnancy and fetal outcomes included miscarriage, stillbirth, baby death and live birth, small-for-gestational-age infants, warfarin embryopathy and warfarin-related fetal loss. Results, Thirty-one women underwent 47 pregnancies. In 34 pregnancies (72.3%), anticoagulation was with predominantly enoxaparin and 13 (27.7%) pregnancies women received mainly warfarin, with enoxaparin given in the first trimester and/or peri-delivery. Seven (14.9%) thrombotic complications occurred, of which five (10.6%) were associated with enoxaparin treatment. Non-compliance or sub-therapeutic anti-Xa levels contributed in each case. Antenatal and postpartum haemorrhagic complications occurred in eight (17%) and 15 (32%) pregnancies respectively. Of 35 pregnancies continuing after 20 weeks' gestation, 96% (22/23) of women taking predominantly enoxaparin had a surviving infant compared with 75% (9/12) in women taking primarily warfarin. Four perinatal deaths occurred, three attributable to warfarin. Conclusions, Compliance with therapeutic dose enoxaparin and aspirin during pregnancy in women with mechanical heart valves is associated with a low risk of valve thrombosis and good fetal outcomes, but close monitoring is essential. [source] Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2010J. Randall Background: This study determined the long-term outcome after colectomy for acute severe ulcerative colitis (ASUC) and assessed whether the duration of in-hospital medical therapy is related to postoperative outcome. Methods: All patients who underwent urgent colectomy and ileostomy for ASUC between 1994 and 2000 were identified from a prospective database. Patient details, preoperative therapy and complications to last follow-up were recorded. Results: Eighty patients were identified, who were treated with intravenous steroids for a median of 6 (range 1,22) days before surgery. Twenty-three (29 per cent) also received intravenous ciclosporin. There were 23 complications in 22 patients in the initial postoperative period. Sixty-eight patients underwent further planned surgery, including restorative ileal pouch,anal anastomosis in 57. During a median follow-up of 5·4 (range 0·5,9·0) years, 48 patients (60 per cent) developed at least one complication. Patients with a major complication at any time during follow-up had a significantly longer duration of medical therapy before colectomy than patients with no major complications (median 8 versus 5 days; P = 0·036). Conclusion: Delayed surgery for patients with ASUC who do not respond to medical therapy is associated with an increased risk of postoperative complications. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Long-term outcomes of revisional surgery following laparoscopic fundoplicationBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 4 2009P. J. Lamb Background: A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long-term clinical outcomes. Methods: Patients requiring late revisional surgery following laparoscopic fundoplication for gastro-oesophageal reflux were identified from a prospective database. Long-term outcomes were determined using a questionnaire evaluating symptom scores for heartburn, dysphagia and satisfaction. Results: The database search found 109 patients, including 98 (5·6 per cent) of 1751 patients who had primary surgery in the authors' unit. Indications for surgical revision were dysphagia (52 patients), recurrent reflux (36), mechanical symptoms related to paraoesophageal herniation (16) and atypical symptoms (five). The median time to revision was 26 months. Outcome data were available for 104 patients (median follow-up 66 months) and satisfaction data for 102, 88 of whom were highly satisfied (62·7 per cent) or satisfied (23·5 per cent) with the outcome. Patients who had revision for dysphagia had a higher incidence of poorly controlled heartburn (20 versus 2 per cent; P = 0·004), troublesome dysphagia (16 versus 6 per cent; P = 0·118) and a lower satisfaction score (P = 0·023) than those with recurrent reflux or paraoesophageal herniation. Conclusion: Revisional surgery following laparoscopic fundoplication can produce good long-term results, but revision for dysphagia has less satisfactory outcomes. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Transanal endoscopic microsurgery is a safe and reliable technique even for complex rectal lesionsBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 7 2008R. J. Darwood Background: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for the excision of rectal lesions, with lower morbidity and mortality rates than open surgery. Following advances in laparoscopic colorectal surgery and endoscopic mucosal resection, this study evaluated the safety and efficacy of TEM in the treatment of complex rectal lesions. Methods: All patients were entered into a prospective database. Complex lesions were identified as high (more than 15 cm from anorectal margin), large (maximum dimension over 8 cm), involving two or more rectal quadrants, or recurrent. Results: Seventy-one lesions (13 carcinomas and 58 tubulovillous adenomas) were identified. The median duration of operation was 60 (interquartile range (i.q.r.) 30,80) min, with an estimated median blood loss of 0 (i.q.r. 0,10) ml. Median hospital stay was 2 (i.q.r. 1,3) days. One patient developed postoperative urinary retention and one returned with rectal bleeding that did not require further surgery. Two patients developed rectal strictures after operation that were dilated successfully. There was no recurrence of benign lesions during a median follow-up of 21 (i.q.r. 6·5,35) months. Conclusion: TEM is a safe technique with low associated morbidity, even when used to excise complex rectal lesions. As such it remains the treatment of choice for rectal lesions not requiring primary radical resection. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 5 2006Y. Kanemitsu Background: The aim of this study was to assess the impact of inferior mesenteric artery (IMA) root nodal dissection before high ligation of the artery on survival in patients with sigmoid colon or rectal cancer. Methods: Data on 1188 consecutive patients who underwent resection for sigmoid colon or rectal cancer, with high ligation of the IMA, were identified from a prospective database (April 1965 to December 1999). Survival of patients with involvement of nodes along the IMA proximal to the origin of the left colic artery (root nodes, station 253) through the bifurcation of the superior rectal artery (trunk nodes, station 252) was determined. Results: Twenty patients (1·7 per cent) had metastatic involvement of station 253 lymph nodes and 99 (8·3 per cent) had metastases to station 252. The 5- and 10-year survival rates of patients with metastases to station 253 were 40 and 21 per cent, and those for patients with metastases to station 252 were 50 and 35 per cent, respectively. Conclusion: High ligation of the IMA allows curative resection and long-term survival in patients with cancer of the sigmoid colon or rectum and nodal metastases at the origin of the IMA. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Comparison of extra-anatomic bypass grafting with angioplasty for atherosclerotic disease of the supra-aortic trunksBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 11 2004B. Modarai Background: Symptomatic stenosis of the supra-aortic trunks (subclavian, innominate and common carotid arteries) can be treated by angioplasty/stenting or surgical bypass. The aim of this study was to compare the initial success and outcome of these two types of treatment. Methods: A prospective database was used to collect information on the presentation, initial success, complications and outcome in 76 patients treated in a single centre between 1983 and 2003. Results: Thirty-five surgical extra-anatomic bypasses were performed, 13 carotid to carotid, 14 carotid to subclavian, two carotid to axillary, three axillary to axillary, one subclavian to axillary and two subclavian to subclavian. One graft occluded after 19 years. No limbs were amputated and no patient had a stroke. The secondary patency rate was 97 per cent at a mean follow-up of 5 years. Forty-one angioplasties were attempted, 34 of the left subclavian, six of the right subclavian and one of the innominate artery. Angioplasty for six subclavian occlusions was unsuccessful. Twenty-seven of 33 arteries remained patent at a mean follow-up of 4 years after a successful endovascular procedure. Conclusion: Extra-anatomic bypass for supra-aortic trunk disease has a better patency than angioplasty, with a comparable complication rate. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Factors predictive of 5-year survival after transarterial chemoembolization for inoperable hepatocellular carcinoma,BRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 3 2003C. B. O'Suilleabhain Background: Transarterial chemoembolization (TACE) is widely used for unresectable hepatocellular carcinoma (HCC), but the long-term survival benefit remains unclear. Methods: Pretreatment variables were analysed for factors predictive of actual 5-year survival from a prospective database of patients with inoperable HCC treated by TACE between 1989 and 1996. Results: Complete 5-year follow-up (median 91 months) was obtained for 320 patients who underwent a median of 4 (range 1,41) TACEs. Median tumour size was 9 (range 1,28) cm. There were 25 5-year survivors (8 per cent), including eight with tumours larger than 10 cm in diameter and three with portal vein branch involvement. On univariate analysis, female gender (P = 0·037), absence of ascites (P = 0·028), platelet count below 150 ×109 per litre (P = 0·011), albumin concentration greater than 35 g/l (P = 0·04), ,-fetoprotein level below 1000 ng/ml (P = 0·007), unilobar tumour (P = 0·027), fewer than three tumours (P = 0·015), absence of venous invasion (P = 0·011), and tumour diameter less than 8 cm (P = 0·021) were significant predictors of 5-year survival. Albumin concentration greater than 35 g/l (P = 0·011), unilobar tumour (P = 0·012) and ,-fetoprotein level below 1000 ng/ml (P = 0·014) were independent prognostic factors on multivariate analysis. Conclusion: Five-year survival is possible with TACE for inoperable HCC, even in some patients with advanced tumours. Unilobar tumours, ,-fetoprotein level below 1000 ng/ml and albumin concentration greater than 35 g/l were factors predictive of 5-year survival. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Cytoreduction including total gastrectomy for pseudomyxoma peritoneiBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 2 2002Dr P. H. Sugarbaker Background: Cytoreductive surgery supplemented by perioperative intraperitoneal chemotherapy is a therapeutic option for selected patients with pseudomyxoma peritonei syndrome. In some patients, the stomach and/or its vascular supply are so covered by mucinous tumour that total gastrectomy is required for complete resection. Methods: Forty-five patients underwent total gastrectomy with a temporary diverting jejunostomy as part of the surgical treatment of pseudomyxoma peritonei syndrome of appendiceal origin. Heated intraoperative intraperitoneal chemotherapy with mitomycin was used in all patients, and 36 had early postoperative intraperitoneal 5-fluorouracil. To date, 39 patients have had second-look surgery and stoma closure; 37 had additional perioperative intraperitoneal chemotherapy. A prospective database was maintained on all patients. Results: The median age was 47 (range 33,66) years. Median interval from diagnosis of pseudomyxoma peritonei to definitive cytoreductive surgery was 23 (range 0,140) months. Six patients presented with intestinal obstruction. The need for gastrectomy was predicted before operation by abdominal computed tomography. Mean operative time was 13 (range 9,17) h. Mean intraoperative requirement for packed red blood cells was 3·0 units, and that for fresh frozen plasma was 9·9 units. Six peritonectomy procedures, including total gastrectomy, were required for complete cytoreduction. All except seven patients were maintained on parenteral nutrition before second-look surgery for jejunostomy closure. All but two patients have resumed oral nutrition with discontinuation of parenteral feeding. There was one postoperative death and one late death. Thirty,seven patients are alive and disease-free, 0,56 months after initiation of treatment. Conclusion: Total gastrectomy with a temporary diverting jejunostomy may be used to facilitate complete cytoreduction in patients with advanced pseudomyxoma peritonei syndrome. © 2002 British Journal of Surgery Society Ltd [source] | ||||||||||||||||||||||||||||