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Median Length (median + length)
Selected AbstractsSelective Application of the Pediatric Ross Procedure Minimizes Autograft FailureCONGENITAL HEART DISEASE, Issue 6 2008David L.S. Morales MD ABSTRACT Objective., Pulmonary autograft aortic root replacement (Ross' operation) is now associated with low operative risk. Recent series suggest that patients with primary aortic insufficiency have diminished autograft durability and that patients with large discrepancies between pulmonary and aortic valve sizes have a low but consistent rate of mortality. Therefore, Ross' operation in these patients has been avoided when possible at Texas Children's Hospital. Our objective was to report outcomes of Ross' operation when selectively employed in pediatric patients with aortic valve disease. Methods., Between July 1996 and February 2006, 55 patients (mean age 6.8 ± 5.5 years) underwent Ross' procedure. Forty-seven patients (85%) had a primary diagnosis of aortic stenosis, three (5%) patients had congenital aortic insufficiency, and five (9%) patients had endocarditis. Forty-two (76%) patients had undergone prior aortic valve intervention (23 [55%] percutaneous balloon aortic valvotomies, 12 [29%] surgical aortic valvotomies, 12 [29%] aortic valve replacements, 2 [5%] aortic valve repairs). Fourteen (25%) patients had ,2 prior aortic valve interventions. Thirty-two patients (58%) had bicuspid aortic valves. Follow-up was 100% at a mean of 3 ± 2.5 years. Results., Hospital and 5-year survival were 100% and 98%, respectively. Morbidity included one reoperation (2%) for bleeding. Median length of hospital stay was 6 days (3 days,3 months). Six (11%) patients needed a right ventricular to pulmonary artery conduit exchange at a median time of 2.3 years. Freedom from moderate or severe neoaortic insufficiency at 6 years is 97%. Autograft reoperation rate secondary to aortic insufficiency or root dilation was 0%. Conclusions., By selectively employing Ross' procedure, outcomes of the Ross procedure in the pediatric population are associated with minimal autograft failure and mortality at mid-term follow-up. [source] Laparoscopic fundoplication in mentally normal children with gastroesophageal reflux diseaseDISEASES OF THE ESOPHAGUS, Issue 2 2002K. V. Menon SUMMARY., Laparoscopic antireflux surgery has been performed in neurologically impaired and scoliotic children. We aimed to assess the effectiveness of laparoscopic fundoplication in mentally normal children with gastroesophageal reflux disease that failed to respond to medical therapy. Data were prospectively collected (symptoms, medical therapy, endoscopies' findings) on 12 children (nine boys, three girls) aged 9,15 years with gastroesophageal reflux disease. Pre- and postoperative ambulatory 24-h pH and DeMeester and Johnson scores were also recorded. Effectiveness of surgery was assessed by comparison of pre- and postoperative total acid exposure time, Visick grade, need for antireflux medication and symptom scores. In total, 11 children underwent a laparoscopic Nissen fundoplication and one underwent a Toupet procedure. Median length of stay was 2 (2,3) nights. The median preoperative pH acid exposure time (AET) was 4.7 (0.8,16.4) percent compared with postoperative AET of 0.4 (0,3) percent. Early postoperative dysphagia occurred in four out of 12 patients, requiring a total of six dilatations. Postoperative Visick scores were: grade I=7 and grade II=5. Laparoscopic fundoplication can be safely performed and is effective in children with GERD who have failed to respond to medical therapy. [source] Utility of the Gyrus open forceps in hepatic parenchymal transectionHPB, Issue 3 2009Matthew R. Porembka Abstract Objective:, This study aimed to evaluate if the Gyrus open forceps is a safe and efficient tool for hepatic parenchymal transection. Background:, Blood loss during hepatic transection remains a significant risk factor for morbidity and mortality associated with liver surgery. Various electrosurgical devices have been engineered to reduce blood loss. The Gyrus open forceps is a bipolar cautery device which has recently been introduced into hepatic surgery. Methods:, We conducted a single-institution, retrospective review of all liver resections performed from November 2005 through November 2007. Patients undergoing resection of at least two liver segments where the Gyrus was the primary method of transection were included. Patient charts were reviewed; clinicopathological data were collected. Results:, Of the 215 open liver resections performed during the study period, 47 patients met the inclusion criteria. Mean patient age was 61 years; 34% were female. The majority required resection for malignant disease (94%); frequent indications included colorectal metastasis (66%), hepatocellular carcinoma (6%) and cholangiocarcinoma (4%). Right hemihepatectomy (49%), left hemihepatectomy (13%) and right trisectionectomy (13%) were the most frequently performed procedures. A total of 26 patients (55%) underwent a major ancillary procedure concurrently. There were no operative mortalities. Median operative time was 220 min (range 97,398 min). Inflow occlusion was required in nine patients (19%) for a median time of 12 min (range 3,30 min). Median total estimated blood loss was 400 ml (range 10,2000 ml) and 10 patients (21%) required perioperative transfusion. All patients had macroscopically negative margins. Median length of stay was 8 days. Two patients (4%) had clinically significant bile leak. The 30-day postoperative mortality was zero. Conclusions:, Use of the Gyrus open forceps appears to be a safe and efficient manner of hepatic parenchymal transection which allows rapid transection with acceptable blood loss, a low rate of perioperative transfusion, and minimal postoperative bile leak. [source] Hospital admissions for acute painful crisis in Trinidad and Tobago.INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY, Issue 5 2006Are the British Committee for Standards in Haematology (BCSH) guidelines applicable? Summary We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia. [source] Does nutritional intervention for patients with hip fractures reduce postoperative complications and improve rehabilitation?JOURNAL OF CLINICAL NURSING, Issue 9 2009Anna-Karin Gunnarsson Aims and objectives., The aims were to investigate whether there were any differences between patients receiving nutritional intervention preoperatively and over five days postoperatively and patients who did not, in terms of postoperative complications, rehabilitation, length of stay and food and liquid intake. Background., Patients with hip fractures are often malnourished at admission to hospital and they typically do not receive the energy and calories needed postoperatively. Design., The design was a quasi-experimental, pre- and post-test comparison group design without random group assignment. Methods., One hundred patients with hip fractures were consecutively included. The control group (n = 50) received regular nutritional support. The intervention group (n = 50) received nutrition according to nutritional guidelines. The outcome measures used were risk of pressure ulcer, pressure ulcers, weight, nosocomial infections, cognitive ability, walking assistance and functional ability, collected preoperatively and five days postoperatively. Each patient's nutrient and liquid intake were assessed daily for five days postoperatively. Results., Significantly fewer (p = 0·043) patients in the intervention group (18%) had pressure ulcers five days postoperatively compared with the control group (36%). Nutrient and liquid intake was significantly higher (p < 0·001) in the intervention group. Median length of stay decreased from nine to seven days (p = 0·137), as did nosocomial infections, from 18,8·7% (p = 0·137). Conclusion., Patients with hip fractures receiving nutrition according to nutritional guidelines developed fewer pressure ulcers. This is invaluable to patients' quality of life and a major economic saving for society. Relevance to clinical practice., Great benefits can be gained for the patients through modest efforts by nurses and physicians such as nutritional intervention. [source] Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosisDISEASES OF THE ESOPHAGUS, Issue 1 2008D. J. Raz SUMMARY. Trans-hiatal esophagectomy with a hand-sewn anastomosis was for 2 decades the preferred approach in our institution for patients with esophageal cancer. In our experience, this anastomotic technique was associated with a 12% leak rate and a 48% rate of stricture requiring dilatation. We sought to determine if a side-to-side intra-thoracic anastomosis was associated with a lower rate of anastomotic stricture and leak. Thirty-three consecutive patients with distal esophageal cancer or Barrett's esophagus with high grade dysplasia underwent a trans-thoracic esophagectomy with a side-to-side stapled intra-thoracic anastomosis. The overall morbidity was 27%, with no anastomotic stricture or leaks. One patient died (3%). The median time to the resumption of an oral diet was 7 days (range 5,28), and the median length of stay in hospital was 9 days (range 6,45). Trans-thoracic esophagectomy with a side-to-side stapled anastomosis is safe and it is associated with a very low rate of anastomotic complications. We consider this to be the procedure of choice for patients with distal esophageal cancers. [source] Endovascular stent implantation for treatment of peripheral artery diseaseEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 3 2007M. Schillinger Endovascular stent implantation is a rapidly emerging technology for treatment of arterial obstructions in the entire circulation. During recent years, several randomized studies evaluated the effects of stenting in lower limb arteries. We herein provide an overview on data of trials in the iliac and femoropopliteal vessel area discussing the benefits and limitations of endovascular stents. In the iliac arteries, midterm and long-term data from one randomized trial including analysis on patency, clinical outcomes, cost-effectiveness and quality of life indicate that balloon angioplasty with selective stenting remains the therapy of choice for endovascular revascularization. In the femoropopliteal arteries, balloon-expanding stents were not superior to balloon angioplasty for treatment of short lesions, and self-expanding nitinol stents also failed to show a beneficial effect in short lesions below 5 cm. However, including longer lesions, one randomized trial indicated a beneficial effect of nitinol stents in lesions with a median length around 10,12 cm. Further studies and longer follow-up intervals are needed to confirm these data. Meanwhile, balloon angioplasty with optional stenting also remains the recommended endovascular approach for the femoropopliteal segment. [source] Bradycardia and sinus arrest during percutaneous ethanol injection therapy for hepatocellular carcinomaEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 3 2004A. Ferlitsch Abstract Background, Percutaneous ethanol injection (PEI) is an established method in the treatment of hepatocellular carcinoma (HCC) and considered a safe procedure, with severe complications occurring rarely. Cardiac arrhythmias have not been reported to date. Aim of the study was to investigate the occurrence of dysrhythmias during PEI. Patients and methods, Twenty-six consecutive patients with inoperable HCC were included. During ultrasound-guided PEI with 95% ethanol, electrocardiogram (ECG) monitoring was performed before starting and continuously during PEI. Results, During PEI a significant reduction in mean heart rate (> 20%) was seen in 15 of 26 (58%) patients. In 11 of 26 patients (42%) occurrence of sinuatrial block (SAB) or atrioventricular block (AVB) was observed after a median time of 9 s (range 4,50) from the start of PEI with a median length of 24 s (range 12,480). Clinical symptoms were seen in two patients, including episodes of unconsciousness, seizure-like symptoms in both and a respiratory arrest during PEI in one patient, requiring mechanical ventilation. In four of 12 patients with repeat interventions, dysrhythmias were reproducible during monthly performed procedures. There was a significant association between the occurrence of SAB or AVB and the amount of instilled alcohol (P = 0·03) and post-PEI serum ethanol levels (P = 0·03). Conclusions, Bradycardia and block formation occur frequently during PEI. These symptoms could be explained by a vasovagal reaction and/or the direct effect of ethanol on the sinus node or the right atrial conduction system. Ethanol dose is an important factor for the occurrence of SAB/AVB. ECG-monitoring seems mandatory during PEI. Prophylactic use of intravenously administered Atropine might be useful. [source] Length of Stay for Older Adults Residing in Nursing Homes at the End of LifeJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2010Anne Kelly MSW OBJECTIVES: To describe lengths of stay of nursing home decedents. DESIGN: Retrospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older. PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006. MEASUREMENTS: The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission. RESULTS: The mean age of decedents was 83.3±9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1,20) and 13.7±18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P<.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke). CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support. [source] Prospective evaluation of the management of moderate to severe cellulitis with parenteral antibiotics at a paediatric day treatment centreJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 4 2008Serge Gouin Aim: To assess the clinical outcome of patients with moderate to severe cellulitis managed at a paediatric day treatment centre (DTC). Methods: Prospective observational study of all patients (3 months to 18 years) with a presumed diagnosis of moderate to severe cellulitis made in a university-affiliated paediatric emergency department (ED) (September 2003 to September 2005). Patients treated at the DTC were given ceftriaxone or clindamycin. Results: During the study period, a presumed diagnosis of moderate to severe cellulitis was made in 224 patients in the ED. Ninety-two patients were treated at the DTC (41%). The cellulitis had a median width of 7.0 cm (range: 1.0,50.0 cm) and a median length of 6.5 cm (range: 1.0,40.0 cm). Blood cultures were performed in 95.7%; one was positive for Staphylococcus aureus. After a mean of 2.5 days of intravenous therapy (first injection in the ED and a mean of 1.5 days at the DTC), 73 patients (79.3%) were successfully discharged from the DTC and switched to an oral agent. For these patients no relapse occurred. Nineteen patients (20.7%) required inpatient admission for further therapy. No patient was diagnosed with necrotizing fasciitis in the course of therapy. Seventy-eight satisfaction questionnaires were handed in and revealed very good to excellent parental satisfaction with treatment at the DTC in 94.8%. Conclusion: Treatment with parenteral antibiotic at a DTC is a viable alternative to hospitalisation for moderate to severe cellulitis in children. [source] Braun enteroenterostomy is associated with reduced delayed gastric emptying and early resumption of oral feeding following pancreaticoduodenectomyJOURNAL OF SURGICAL ONCOLOGY, Issue 5 2010Steven N. Hochwald MD Abstract Background and Objectives Morbidity rates following pancreaticoduodenectomy (PD) remain high with delayed gastric emptying (DGE) and slow resumption of oral diet contributing to increased postoperative length of stay. A Braun enteroenterostomy has been shown to decrease bile reflux following gastric resection. We hypothesize that addition of Braun enteroenterostomy during PD would reduce the sequelae of DGE. Methods From our PD database, patients were identified that underwent classic PD with partial gastrectomy from 2001 to 2006. All patients with reconstruction utilizing a single loop of jejunum at the University of Florida Shands Hospital were reviewed. Demographics, presenting signs and symptoms, pathologic diagnoses, and postoperative morbidity were compared in those patients undergoing reconstruction with an additional Braun enteroenterostomy (n,=,70) to those not undergoing a Braun enteroenterostomy (n,=,35). Results Patients undergoing a Braun had NG tubes removed earlier (Braun: 2 days, no Braun: 3 days, P,=,0.002) and no significant change in postoperative vomiting (Braun: 27%, no Braun: 37%, P,=,0.37) or NG tube reinsertion rates (Braun: 17%, no Braun: 29%, P,=,0.21). Median postoperative day with tolerance of oral liquids (Braun: 5, no Braun: 6, P,=,0.01) and solid diets (Braun: 7, no Braun: 9, P,=,0.01) were significantly sooner in the Braun group. DGE defined by two criteria including the inability to have oral intake by postoperative day 10 (Braun: 10%, no Braun: 26%, P,<,0.05) and the international grading criteria (grades B and C, Braun: 7% vs. no Braun: 31%, P,=,0.003) were significantly reduced in those undergoing the Braun procedure. In addition, the median length of stay (Braun: 10 days, no Braun: 12 days, P,<,0.05) was significantly reduced in those undergoing the Braun procedure. The rate of pancreatic anastomotic failure was similar in the two groups (Braun: 17% vs. no Braun: 14%, P,=,0.79). Median bile reflux was 0% in those undergoing a Braun. Conclusions The present study suggests that Braun enteroenterostomy can be safely performed in patients undergoing PD and may reduce the indicence of DGE and its sequelae. Further studies of Braun enteroenterostomy in larger randomized trials of patients undergoing PD are warranted. J. Surg. Oncol. 2010; 101:351,355. © 2010 Wiley-Liss, Inc. [source] Graft weight/recipient weight ratio: How well does it predict outcome after partial liver transplants?LIVER TRANSPLANTATION, Issue 9 2009Mark J. Hill Partial graft liver recipients with graft weight/recipient weight (GW/RW) ratios < 0.8% are thought to have a higher incidence of postoperative complications, including small-for-size syndrome (SFSS). We analyzed a cohort of such recipients and compared those with GW/RW < 0.8% to those with GW/RW , 0.8%. Between 1999 and 2008, 107 adult patients underwent partial graft liver transplants: 76 from live donors [living donor liver transplantation (LDLT)] and 31 from deceased donors [split liver transplantation (SLT)]. Of these, 22 had GW/RW < 0.8% (12 with LDLT and 10 with SLT), and 85 had GW/RW , 0.8% (64 with LDLT and 21 with SLT). The baseline demographics and median length of follow-up were similar. SFSS developed in 3 recipients with GW/RW < 0.8% (13.6%) and in 8 recipients with GW/RW , 0.8% (9.4%; P = not significant). Other early complications were similar between the 2 groups. Inflow modification with splenic artery occlusion was performed in 13 recipients: 7 with GW/RW < 0.8% and 6 with GW/RW , 0.8%. Graft survival at 1 year post-transplant did not differ (91% versus 92%; P = not significant). In conclusion, GW/RW did not appear to be the only determinant of outcome after partial liver transplantation. Using techniques such as inflow modification may help to prevent some of the problems seen with smaller grafts. Liver Transpl 15:1056,1062, 2009. © 2009 AASLD. [source] Risk factors for nosocomial intensive care infection: a long-term prospective analysisACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 6 2001P. Appelgren Background: To identify risk factors for nosocomial infection in intensive care and to provide a basis for allocation of resources. Methods: Long-term prospective incidence study of risk factors for nosocomial infection in the surgical-medical intensive care unit of a university hospital. Results: A total of 2671 patients were admitted during four years, and 562 of 574 patients staying >48 h were observed during 4921 patient days (median length of stay 5 days, range 2,114). Of these, 196 (34%) patients had 364 nosocomial infections after median 8,10 days, an infection rate of 14/100 admissions. Infection prolonged length of stay 8,9 days and doubled the risk of death. The infections were 17% blood stream, 26% pneumonias, 34% wound, 10% urinary tract and 13% other infections. The incidence of bloodstream infection declined significantly during the study years, from 12% to 5%. In multiple regression analysis, the important variables for infection were central venous catheter, mechanical ventilation, pleural drainage and trauma with open fractures. High age, immunosuppression and infection on admission did not influence the risk of acquiring infection. Trauma patients constituted 24% of the study population. Trauma with open fractures increased the risk of infection more than twice (P=0.003), mainly due to wound infections. Conclusion: Trauma cases, with open fractures, were the patients most at risk of infection, despite low disease severity scores. Resources to prevent nosocomial infection should be allocated to these patients. [source] Toward Evidence-Based Prescribing at End of Life: A Comparative Analysis of Sustained-Release Morphine, Oxycodone, and Transdermal Fentanyl, with Pain, Constipation, and Caregiver Interaction Outcomes in Hospice PatientsPAIN MEDICINE, Issue 4 2006BCPS, Douglas J. Weschules PharmD ABSTRACT Objective., The primary goal of this investigation was to examine selected outcomes in hospice patients who are prescribed one of three sustained-release opioid preparations. The outcomes examined include: pain score, constipation severity, and ability of the patient to communicate with caregivers. Patients and Settings., This study included 12,000 terminally ill patients consecutively admitted to hospices and receiving pharmaceutical care services between the period of July 1 and December 31, 2002. Design., We retrospectively examined prescribing patterns of sustained-release morphine, oxycodone, and transdermal fentanyl. We compared individual opioids on the aforementioned outcome markers, as well as patient gender, terminal diagnosis, and median length of stay. Results., Patients prescribed a sustained-release opioid had similar average ratings of pain and constipation severity, regardless of the agent chosen. Patients prescribed transdermal fentanyl were reported to have more difficulty communicating with friends and family when compared with patients prescribed either morphine or oxycodone. On average, patients prescribed transdermal fentanyl had a shorter length of stay on hospice as compared with those receiving morphine or oxycodone. Conclusion., There was no difference in observed pain or constipation severity among patients prescribed sustained-release opioid preparations. Patients receiving fentanyl were likely to have been prescribed the medication due to advanced illness and associated dysphagia. Diminished ability to communicate with caregivers and a shorter hospice course would be consistent with this profile. Further investigation is warranted to examine the correlation between a patient's ability to interact with caregivers and pain control achieved. [source] Accuracy of prediction of walking for young stroke patients by use of the FIMPHYSIOTHERAPY RESEARCH INTERNATIONAL, Issue 1 2001Heather Thornton Senior Lecturer Abstract Background and Purpose Clinical prediction of walking outcome after a stroke is essential for effective discharge planning. However, its accuracy has hardly been explored. This study took place in a regional unit admitting patients with complex neurological disabilities for specialist inpatient rehabilitation. The aim was to compare predicted outcome (goal score) with achieved outcome (discharge score) on the seven-point locomotion subscale of the Functional Independence Measure (FIM), to evaluate its precision and identify factors influencing accuracy. Method Admission, goal and discharge scores were analysed retrospectively for 141 subjects (90 M; 51 F) admitted consecutively to the Unit with median age 54 years (range 15,68 years) with median length of stay 13.6 weeks (range 3,35 weeks). Results Ninety subjects (64%) gained from two to six points; 50 subjects (35%) gained one point or showed no change. One patient deteriorated by two points. Excluding patients admitted with the highest score (FIM level 7), the overall level of agreement between predicted and discharge scores was moderate (weighted kappa 0.47). Prediction was accurate to ±1 point in 113 subjects (80%). Overprediction by ,2 points occurred in 16 subjects (11%) and underprediction by ,2 points in 12 subjects (9%). Analysis of the most-disabled cohort, admitted with FIM levels 1 or 2 scores, revealed a higher sensitivity for predicting ,independence' (FIM levels 5,7) (78%) than ,dependence' (FIM levels 1,4) (65%). Accuracy was not affected by age, gender or side of stroke. Inaccurate predictions were associated with lower admission FIM level scores (p=,0.26;p=0.002) and a greater length of stay (p=0.36;p<0.001). Subjects with quad-riplegia were more likely to have inaccurate outcome predictions made than those with hemiplegia (p=0.025) and those with neglect were more likely to have inaccurate outcome predictions made than those without neglect (p=0.017). Conclusion Further investigation into clinical prediction and the variables which confound accuracy is needed for effective planning. Copyright © 2001 Whurr Publishers Ltd. [source] Oesophagectomy for tumours and dysplasia of the oesophagus and gastro-oesophageal junctionANZ JOURNAL OF SURGERY, Issue 4 2009Krishna Epari Abstract Background:, Neoadjuvant therapy, radical lymphadenectomy and treatment in high-volume centres have been proposed to improve outcomes for resectable oesophageal tumours. The aim of the present study was to review the oesophagectomy experience of a single surgeon with a moderate caseload who uses neoadjuvant therapy selectively and performs a conservative lymphadenectomy. Methods:, A retrospective review of prospectively collected data was performed. The study included 125 consecutive attempted oesophageal resections performed by a single surgeon (RC) from 1993 to 2006. Results:, All patients were staged with computed tomography and also laparoscopy for lower third and junctional tumours. Endoscopic ultrasound was used in 69%. Seventy-seven per cent were adenocarcinomas. Neoadjuvant therapy was used selectively in 23%. One hundred and twenty-one resections were carried out, giving an overall resection rate of 97% with an R0 resection in 82%. In-hospital mortality was 0.8%, clinical anastomotic leak 1.7% and median length of stay 14 days. Overall median and 5-year survival were 46 months and 47%. Stage-specific 5-year survival was 100%, 71%, 41% and 21% for stages 0, I, II and III, respectively. Isolated local recurrence occurred in 8%. Conclusions:, A moderate volume surgeon with specialist training in oesophageal resectional surgery can achieve a low mortality and anastomotic leak rate with good survival outcomes. The role for neoadjuvant therapy and radical lymphadenectomy is controversial and remains to be clearly defined. Accurate preoperative staging is essential for selection of patients for curative surgery with or without neoadjuvant therapy and for comparison of results. [source] GS28P LAPAROSCOPIC CHOLECYSTECTOMY FOR OBESE PATIENTSANZ JOURNAL OF SURGERY, Issue 2007S. W. Li Background Laparoscopic surgery is often perceived to be more difficult for obese patients. Middlemore Hospital has unique patient population with high prevalence of obesity. This is a pilot study to compare the outcome of obese and non-obese patients who had laparoscopic cholecystectomy in our institution. Our hypothesis is that obese patients do not suffer more adverse postoperative outcome. Methods We reviewed all patients undergoing acute and elective cholecystectomy from January 2004 to December 2006, 100 obese patients were identified. The control group consists of 100 non-obese patients matched for age, sex and type of admission. Outcome assessed includes length of recovery period, complication and conversion rate. Results Over the three year period there were 1400 cholecystectomies, of which 96% were commenced laparoscopically. Overall conversion rate was 3.8%. The obese group has increased rate of wound complication (10% vs 2%, p = 0.037) and conversion rate (8% vs 3.5%, p = 0.28). The two study groups have similar median length of postoperative stay of 4 days. Conclusion This confirms our hypothesis that it is safe for obese patients to have laparoscopic cholecystectomy. However there is increased risk of conversion and wound complication. [source] Heat-shock protein 70 gene polymorphism is associated with the severity of diabetic foot ulcer and the outcome of surgical treatmentBRITISH JOURNAL OF SURGERY (NOW INCLUDES EUROPEAN JOURNAL OF SURGERY), Issue 10 2009K. A. Mir Background: Foot ulcer is a significant cause of morbidity in diabetics. Genetic make-up can determine inflammatory and healing responses. This study examined the hypothesis that specific polymorphisms of the heat-shock protein 70 gene could predispose to the severity of diabetic foot ulceration. Methods: Some 106 consecutive diabetic patients (101 evaluable) with foot ulceration admitted to a tertiary care hospital were managed according to a standard protocol. DNA was extracted from venous blood and examined by polymerase chain reaction,restriction fragment length analysis for two specific polymorphisms: G1538A in the HSPA1B and C2437T in the HSPA1L gene. Results: HSPA1B genotyping showed that 70 patients were AG and 30 GG (one not amplified). The AG genotype was significantly associated with the severity of foot ulceration (Wagner grade) (P = 0·008, ,2 test), need for amputation (relative risk 2·02, 95 per cent confidence interval 1·02 to 4·01; P = 0·025) and median length of hospital stay (8 versus 5 days for GG; P = 0·043). HSPA1L genotypes (78 TT, 22 CT, one CC) did not show any significant association with these parameters. Conclusion: The HSPA1B genotype, was associated with the severity of diabetic foot ulceration, need for amputation and duration of hospitalization in these patients. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source] Predictors of avascular necrosis of bone in long-term survivors of hematopoietic cell transplantationCANCER, Issue 18 2009Stephanie Campbell BA Abstract BACKGROUND: Avascular necrosis (AVN) is a debilitating condition reported after chronic steroid use. The purpose of this study was to describe the magnitude of risk in individuals who survived ,1 years after hematopoietic cell transplantation (HCT), and to investigate the role of immunosuppressive agents such as prednisone, tacrolimus (FK506), mycophenolate mofetil (MMF), and cyclosporine (CSA) in the development of AVN after HCT. METHODS: Using a retrospective study design, the authors followed 1346 eligible patients for the development of AVN. Cumulative incidence was calculated taking into consideration competing risk from death and disease recurrence. Cox proportional regression techniques were used to identify associated risk factors. RESULTS: The median age at HCT was 34 years (range, 7 months-69 years), and median length of follow-up for those surviving was 8.2 years. Seventy-five patients developed AVN of 160 joints. The cumulative incidence of AVN at 10 years was 2.9% after autologous HCT, 5.4% after allogeneic matched related donor HCT, and 15% after unrelated donor HCT (P < .001 compared with autologous HCT recipients). For allogeneic transplant recipients, male sex (relative risk [RR], 2.1; 95% confidence interval [95% CI], 1.1-4.0); presence of chronic graft-versus-host disease (RR, 2.2); and exposure to CSA, FK506, prednisone, and MMF rendered patients at increased risk, especially in patients with a history of exposure to ,3 drugs (RR, 9.2; 95% CI, 2.42-35.24). CONCLUSIONS: Future studies examining the pathogenetic mechanism underlying AVN should help develop targeted interventions to prevent this chronic debilitating condition. Cancer 2009. © 2009 American Cancer Society. [source] An interinstitutional and interspecialty comparison of treatment outcome data for patients with prostate carcinoma based on predefined prognostic categories and minimum follow-up,CANCER, Issue 10 2002Frank A. Vicini M.D. Abstract BACKGROUND The optimal management of patients with clinically localized prostate carcinoma remains undefined due in part to the absence of well-designed, prospective, randomized trials. The current study was conducted to compare and contrast outcomes with different forms of therapy for patients with prostate carcinoma who were treated at several institutions using predefined prognostic categories. METHODS A retrospective study of 6877 men with prostate carcinoma who were treated between 1989 and 1998 at 7 different institutions with 6 different types of therapy was conducted. Five-year actuarial rates of prostate specific antigen (PSA) failure were calculated based on predefined prognostic categories, which included combinations of pretreatment PSA level, tumor stage, and Gleason score. In addition, outcome was calculated using consistent biochemical failure definitions and a minimum, median length of follow-up. RESULTS Substantial differences in outcome were observed for the same type of treatment and at the same institution, depending on the number of prognostic variables used to define treatment groups. However, estimates of 5-year PSA outcomes after all forms of therapy for low-risk and intermediate-risk patient groups were remarkably similar (regardless of the type of treatment) when all three pretreatment variables were used to define prognostic categories. For patients in high-risk groups, the 5-year PSA outcomes were suboptimal, regardless of the treatment technique used. CONCLUSIONS The current data suggest that interinstitutional and interspecialty comparisons of treatment outcome for patients with prostate carcinoma are possible but that results must be based on all major prognostic variables to be meaningful. Analyzed in this fashion, 5-year PSA results were similar for patients in low-risk and intermediate-risk groups, regardless of the form of therapy. Findings from prospective, randomized trials using survival (cause specific and overall) as the end point for judging treatment efficacy and longer follow-up will be needed to validate these findings and to identify the most appropriate management option for patients with all stages of disease. Cancer 2002;95:2126,35. © 2002 American Cancer Society. DOI 10.1002/cncr.10919 [source] Paediatric poisonings treated in one Finnish main university hospital between 2002 and 2006ACTA PAEDIATRICA, Issue 6 2008Juho E Kivistö Abstract Aim: Acute poisonings are a major cause of morbidity among children. This study aims to describe the incidence and nature of emergency visits for acute paediatric poisoning among Finnish children. Methods: All patients younger than 16 years admitted to the Tampere University Hospital's emergency department with a diagnosis of poisoning during 2002,2006 were identified from the Hospital Information System using the International Classification of Diseases (ICD-10). Results: Altogether 369 emergency visits were diagnosed with poisoning, the overall incidence being 8.1 per 10 000 person,years (95% CI 7.3,9.0). A majority of patients were adolescents aged 10,15 years (48%) and children under 5 years (45%). Boys represented 55% of the cases. Nonpharmaceutical agents were suspected to be the cause in 60.4% and pharmaceuticals in 30.6% of the intoxications. Multiple agents were involved in 8.4% of the cases. Ethanol was the agent in 30.9% of the poisonings. Most patients (78.9%) were hospitalized (median length of stay 1 day). Overall mortality was 0.3%. Conclusion: Acute paediatric poisonings represent a relatively frequent problem in Finland, and remain a life-threatening problem. The high proportion of alcohol poisonings highlights the necessity to develop more effective primary prevention programs. [source] A randomised controlled trial of routine suction drainage after elective thyroid and parathyroid surgery with ultrasound evaluation of fluid collectionCLINICAL OTOLARYNGOLOGY, Issue 1 2007S. Ahluwalia Objective:, To determine the need for suction drainage after elective thyroid and parathyroid surgery. Design:, Randomised controlled trial. Setting:, University teaching hospital. Participants:, Patients requiring elective thyroid or parathyroid surgery were recruited and informed consent was obtained (n = 100). Before wound closure, patients were randomised into either group A (to remain without suction drainage) or group B (to receive suction drainage). Excluded patients were those requiring associated neck dissection and those with bleeding diatheses, all of whom would necessarily require drainage in our unit. Main outcome measures:, Primary , ultrasound evaluation of any collection in the thyroid bed, performed 1-day postoperatively. Secondary , postoperative complications; length of in-patient stay. Results:, One hundred patients completed the study, and groups A and B comprised 50 patients each. Patients in each group exhibited a mean age of 49 years, and a male to female ratio of 1 : 9. Both groups were also well-matched regarding type of operation, size of tumour and histopathological diagnosis. Modal and median postoperative neck collection volume on ultrasound examination was 0 and 0 cm3 respectively (range 0,16 cm3) in group A and was 0 and 0 cm3 (range 0,70 cm3) in group B. This difference was not statistically significant, but three patients with a haematoma were all in the suction drainage group. Difference in complication rates between groups was also not statistically significant. Modal and median length of in-patient stay was 2 and 2 days respectively (range 2,3 days) in group A and 3 and 3 days (range 2,4 days) in group B, and this difference was statistically significant (P = 0.0006). Conclusion:, Routine suction drainage after uncomplicated elective thyroid and parathyroid surgery appears unnecessary, and prolongs in-patient stay. [source] | ||||||||||||||||||||||||||||