Background Minimally invasive Ivor Lewis esophagectomy (MIE) is gaining popularity for the treatment of esophageal cancer. However, as it is a technically demanding operation, a learning curve should ...be defined to guide training and allow implementation at institutions not currently using this technique. Study Design Our study included a retrospective series of the first 80 consecutive patients undergoing MIE by a single surgeon with advanced training in minimally invasive esophageal surgery in independent practice at a high-volume tertiary center. Patients were stratified into 2 groups of 40 patients, with chronological order defining early and late experiences. Primary end points included conversion to open procedure, surgical time, blood loss, chest drainage duration, time to oral intake, hospital stay, postoperative morbidity, and mortality. The cumulative sum methodology was used and analyzed by visually inspecting the plots. Results Conversion to open procedure occurred in 2 (5%) patients in the early group and none in the late group (p = 0.49). Comparing early vs late experience, mean surgical time was 364 vs 316 minutes (p < 0.01), estimated blood loss was 205 vs 176 mL (p = 0.14), median hospital stay was 7 vs 6 days (p < 0.01), and morbidity was observed in 16 (40%) and 14 (35%) patients (p = 0.82), respectively. There were no anastomotic leaks or 30-day mortality. Cumulative sum plots showed decreasing surgical time after patient 54 (plateau after patient 31), decreasing chest tube duration after patients 38 and 33, sooner oral intake after patient 35, and decreased hospital stay after patient 33. Conclusions Improved operative and perioperative parameters for MIE were observed in the last 40 patients when compared with the first 40 patients. A reasonable learning curve for MIE would require the operation and perioperative care of 35 to 40 patients.
Abstract Objective Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of ...this study is to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects. Methods Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic, namely aortic homograft or acellular dermal matrix. Results Eight patients, three males and five females with a mean age of 54±13 years, underwent closure of complex central airway defects with bioprosthetic material. All but one patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, while five had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n=5), the anterior wall of the trachea (n=1) or the main stem bronchus (n=2). Five reconstructions were with aortic homograft and three with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n=4), omentum (n=2), or left unbuttressed (n=2). The airway defect was successfully closed in all patients. There was no post-operative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and one additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%). Conclusions Bioprosthetics represent a viable option for management of large airway defects, including airway-enteric fistula that exceed the limits of primary repair. Perspective Statement Central airway defects whose size and complexity preclude primary repair present a challenging clinical problem. We examined the role of bioprosthetics (aortic homograft and acellular dermal matrix) in the repair of non-circumferential defects. In our experience these materials provide airtight closure and correction of complex defects in otherwise difficult to manage patients.
Background Although commonly used in combination with irinotecan or oxaliplatin (iri/oxal) for treatment of colorectal liver metastases before extirpation, the effects of preoperative bevacizumab on ...surgical outcomes are not established. The objective of this retrospective study was to determine if addition of bevacizumab to iri/oxal preoperative chemotherapy increases morbidity after hepatic resection. Study Design We compared demographics, clinicopathologic data, treatments, and postoperative outcomes between patients given preoperative iri/oxal with and without bevacizumab and patients who underwent hepatic resection within and after 8 weeks from the last dose of bevacizumab. Results From 1996 to 2006, 96 patients were treated with preoperative iri/oxal; 39 (40.6%) received concurrent bevacizumab. Preoperative bevacizumab treatment was associated with less blood loss (median 425 mL versus 600 mL, p = 0.01) and lower RBC transfusion rates (43.9% versus 23.1%, p = 0.06) after partial hepatectomy on univariable analysis. Only age ≥ 70 years (hazard ratio = 8.52, 95% CI 2.00 to 36.45) and concurrent extrahepatic procedures (hazard ratio = 4.12, 95% CI 1.49 to 11.39) independently predicted RBC transfusion and overall complications, respectively. There were no differences in overall (43.6% versus 38.6%), severe (28.2% versus 24.6%), hepatic (17.9% versus 26.3%), wound (10.3% versus 7%), or thromboembolic or bleeding (2.6% versus 5.3%) complications (all p > 0.05). For patients treated with iri/oxal and bevacizumab, overall complications were more common when resection was performed within 8 weeks after the last bevacizumab dose (62.5% versus 30.4%), but this difference was not statistically significant (p = 0.06). Conclusions If discontinued at least 8 weeks before hepatic resection, addition of bevacizumab to preoperative iri/oxal does not increase morbidity after hepatic resection.
Bone morphogenetic protein receptor type 2 (BMPR2) mutations occur in idiopathic and familial pulmonary arterial hypertension (IPAH, FPAH); however, the impact of these mutations on clinical ...assessment and disease severity remains unclear. We investigated the role of BMPR2 mutations on acute vasoreactivity and disease severity in IPAH/FPAH children and adults.
BMPR2 mutation types were determined in 147 IPAH/FPAH patients. Hemodynamics were obtained at baseline and with acute vasodilator testing.
Of 147 patients (69 adults, 78 children; 114 with IPAH, 33 with FPAH), 124 (84%) were BMPR2 mutation-negative, and 23 (16%) were mutation-positive. BMPR2 mutation-positive patients were less likely to respond to acute vasodilator testing than mutation-negative patients (4% vs 33%; p < 0.003; n = 147). BMPR2 mutation-positive children also appeared less likely to respond to acute vasodilator testing than mutation-negative children. BMPR2-positive patients had lower mixed venous saturation (57 +/- 9% vs 62 +/- 10%; p < 0.05) and cardiac index (CI; 2.0 +/- 1.1 vs 2.4 +/- 1.5 liters/min; p < 0.05) than BMPR2-negative patients.
Patients with BMPR2 mutations are less likely to respond to acute vasodilator testing than mutation-negative patients and appear to have more severe disease at diagnosis. Determination of BMPR2 mutations appears to help identify IPAH/FPAH children and adults who are unlikely to respond to acute vasodilator testing and, thus, unlikely to benefit from calcium channel blockade (CCB) treatment.
We studied the nitrogen biogeochemistry of the ice‐covered eastern Bering Sea shelf using the isotope ratios (15N/14N and 18O/16O) of NO3− and other N species. The 15N/14N of late winter NO3− on the ...shelf decreases inshore and is inversely correlated with bottom water NH4+, consistent with an input of low‐15N/14N NO3− from partial nitrification of NH4+ remineralized from the sediments. An inshore 15N/14N increase in total dissolved N (TDN) suggests that (1) the sediment‐derived NH4+ is elevated in 15N due to the same partial nitrification that yields the low‐15N/14N NO3−, and (2) 15N‐deplete NO3− from partial nitrification within the sediments is denitrified to N2. The proportion of newly nitrified NO3− on the shelf, evidenced by an inshore decrease in NO3− 18O/16O, is correlated with the N deficit, further implicating nitrification coupled to denitrification; however, a simple N isotope budget indicates a comparable rate of denitrification supported by diffusion of NO3− into the sediments. The isotopic impact of benthic N loss is further demonstrated by a correlation between the 15N/14N of shelf surface sediment and the N deficit of the overlying water column, both of which increase inshore and northward, as well as by Arctic NO3− isotope data indicating that the fixed N transported through Bering Strait has a 15N/14N higher than is found in the open Bering Sea. The significant net isotope effect of benthic N loss on the Bering shelf, 6–8 ‰, is at odds with previous assumptions regarding the global ocean's N isotope budget.
Key Points
Benthic processes influence the fixed N burden of the water column
Sediment remobilization contributes to seasonal nutrient recharge under sea ice
Benthic denitrification imprints 15N‐enrichment to shelf fixed N
Background:. Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI). Methods:. ...Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence. Conclusions:. Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.
Background This study seeks to evaluate the use of postoperative pyloric balloon dilatation for delayed gastric emptying after esophageal substitution with gastric conduit. Methods A total of 436 ...patients underwent esophagectomy with gastric conduit from 2002 to 2009. All approaches to esophagectomy were included except patients with alternative reconstruction or emergent esophagectomy. Gastric conduit diameter, anastomotic location, and mediastinal route were variable. Gastric outlet obstruction (GOO) was strictly defined to include patients with clinical and radiographic delayed gastric emptying requiring intervention. Results Gastric outlet obstruction was found in 22% (98 of 436) of patients who underwent esophagectomy. Pyloromytomy was performed on 52% (51 of 98) of these patients and employed in 41% (179 of 436) of patients in the entire cohort. GOO was present in 28% (51 of 179) of patients who underwent a pyloric drainage procedure compared with 18% (47 of 257) of patients with no pyloric intervention ( p = 0.01). Endoscopic balloon dilatation of the pylorus was used to treat 39% (38 of 98) of patients with delayed gastric emptying yielding a 95% (36 of 98) success rate. Pyloric dilatations were performed with controlled radial expansion esophageal balloon dilators (range,10 to 20 mm). The remaining patients were treated conservatively with prokinetics, nasogastric drainage, or observation. Nasogastric drainage was employed for 7.4 ± 4.4 days in patients with GOO and 6.8 ± 4.0 days in asymptomatic patients ( p = 0.15). Neoadjuvant chemoradiotherapy did not contribute to increased incidence of GOO. There was a significant difference in postoperative pneumonia (18.4% vs 10.6%, p = 0.05) and median length of hospital stay (12 ± 16 vs 10 ± 9 days, p < 0.0001) in patients with GOO versus normal emptying. Conclusions Delayed gastric emptying after esophageal substitution with gastric conduit can be adequately treated with balloon dilatation of the pylorus despite an operative drainage procedure.
Ocular psoriasis Rehal, Balvinder, BS; Modjtahedi, Bobeck S., MD; Morse, Lawrence S., MD, PhD ...
Journal of the American Academy of Dermatology,
12/2011, Letnik:
65, Številka:
6
Journal Article
Recenzirano
Background Psoriasis is associated with several extracutaneous manifestations of which ocular complications are common. Signs and symptoms of ocular psoriasis may be subtle and overlooked. The ...dermatologic literature has generally underaddressed these complications; however, a thorough understanding of ophthalmic involvement is important to the comprehensive care of patients with psoriasis. Objective We sought to provide a complete and up-to-date clinical guide on the manifestations and diagnostic considerations of ocular psoriasis. Methods PubMed and Google Scholar were used to find primary resources. The MeSH database of PubMed was used to link key ocular terms with the words “psoriasis,” “psoriatic arthritis,” and/or various psoriasis medications. Results Ocular manifestations of psoriasis are discussed anatomically to allow for easy clinical reference. Complications include direct cutaneous effects such as eyelid involvement and blepharitis, and immune-mediated conditions such as uveitis. Limitations Literature reviewed was primarily focused on English-language journals. In addition, older articles not included in the above electronic databases were underrepresented. Conclusion Ophthalmic complications of psoriasis are numerous and affect almost any part of the eye; however, they may be easily missed. Physicians should maintain a high index of suspicion that ophthalmic symptoms in patients with psoriasis may be related to their underlying disease, even though signs and symptoms are often vague. Screening and evaluation guidelines for ocular disease should be more clearly incorporated into the already large academic framework of psoriasis research and care.
Background Recent policy changes by insurance companies have been instituted to encourage vaginal hysterectomy (VH) as the preferred route for removal of the uterus. It is not known if advantages of ...VH for benign indications apply to women with gynecologic cancer. Objective The goal of this study was to assess trends in surgical approach to hysterectomy among gynecologic cancer patients and to evaluate outcomes by approach. We hypothesized that, among gynecologic oncology patients, postoperative complications and hospital stay would differ by surgical approach, and that advantages of VH for benign indications may not apply to gynecologic cancer patients. Study Design We performed a population-based retrospective cohort study of cervical, endometrial, or ovarian/fallopian tube cancer patients treated surgically in Washington State from 2004 through 2013 using the Comprehensive Hospital Abstract Reporting System. Surgery was categorized as abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or VH. We determined rate of surgical approach by year and the association with length of stay, 30-day readmission rate, and perioperative complications. Results We identified 10,117 patients who underwent surgery for gynecologic cancer, with 346 (3.4%) VH, 2698 (26.7%) LH, and 7073 (69.9%) AH. Patients undergoing AH had more comorbidities than patients with VH or LH (Charlson Comorbidity Index ≥2: 11.3%, 7.9%, and 8.1%, respectively; P < .001). From 2004 through 2013 AH and VH declined (94.4-47.9% and 4.4-0.8%, respectively; P < .001) while LH increased from 1.2-51.4% in 2013 ( P < .001). Mean length of stay was 4.6 days for women undergoing AH and was 1.9 days shorter for VH (95% confidence interval, 1.6–2.3 days) and 2.6 days shorter for LH (95% confidence interval, 2.4–2.7 days) ( P < .001). Risk of 30-day readmission for patients undergoing LH was 40% less likely compared to AH but not different for VH vs AH. Conclusion AH and LH remain the preferred routes for hysterectomy in gynecologic oncology. Over the past decade, there has been a significant shift to LH with lower 30-day readmission and complication rates. There may be a limited role for VH in select patients. Current efforts to standardize the surgical approach to hysterectomy should not apply to patients with known or suspected gynecologic cancer.
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