Pacemakers and Implantable Cardiac Defibrillators in Dermatologic Surgery

BACKGROUND: Electrosurgery used during dermatologic surgical procedures can cause malfunction of pacemakers and implantable cardiac defibrillators (ICDs), producing problems with rhythm detection, proper function, or alteration of the device. Well-documented safety data on electrosurgery in patients with cardiac devices are limited. At Mayo Clinic in Rochester, Minnesota, the Pacemaker Clinic manages all patients with pacemakers and ICDs undergoing dermatologic surgery. The preoperative and postoperative evaluations provide a unique opportunity to evaluate the safety of dermatologic surgery with electrosurgery in such patients. OBJECTIVES: The objective was to review the evaluation and management, by an experienced cardiology team, of patients with cardiac devices undergoing dermatologic surgery and to characterize perioperative complications. METHODS: A retrospective chart review of all patients identified with pacemakers or ICDs undergoing Mohs micrographic or dermatologic excisional surgery with electrosurgery at Mayo Clinic 2001 through 2004 were identified. Data were abstracted to identify any possible complications. RESULTS: The 173 patients with pacemakers and 13 with ICDs undergoing dermatologic surgery had no documented complications from electrosurgery. CONCLUSION: The lack of complications associated with pacemakers and ICDs with electrosurgery is reassuring. The authors support published recommendations about techniques and precautions to optimize safety during electrosurgery in patients with cardiac devices. The care of patients with ICDs in particular requires special consideration.     

Conservative Surgery for Breast Carcinoma Associated with Pregnancy

Abstract: Thirty-five patients with pregnancy-associated breast carcinoma diagnosed between 1985 and 1995 were identified and characterized from a prospectively generated database. Twenty-two of these patients had stage 1 or 2 disease and were therefore potential candiates for conservative surgical management. The median age was 36 years. Two thirds of the patients were pregnant at the time of diagnosis; the median gestational age of the fetus at diagnosis was 7 months. Twenty-one of the 22 of the patients presented with a palpable mass. The majority of tumors were estrogen-receptor negative. Nine patients were treated with breast-conservation therapy, and 13 were treated with mastectomy. In the breast-conservation therapy group, there were three distant recurrences and no local recurrences with a median follow-up of 24 months. In the mastectomy group, two patients developed distant metastases and one developed a local recurrence with a median follow-up of 28 months. The results of breast-conservation therapy are similar to the results of mastectomy for stage 1 and 2 cancers associated with pregnancy. Therefore, breast-conservation therapy is an option for selected patients with pregnancy-associated breast cancer.     

Outcomes Associated with Surgery for T4 Esophageal Cancer

Background

T4 esophageal cancer often portends a dismal prognosis even after surgical resection. Historical incomplete resections and poor survival rates often make surgery palliative rather than curative.

Methods

Using a comprehensive esophageal cancer database, we identified patients who underwent an esophagectomy for T4 tumors between 1994 and 2011. Neoadjuvant treatment (NT) and pathologic response variables were recorded, and response was denoted as complete response (pCR), partial response (pPR), and nonresponse (NR). Clinical and pathologic data were compared. Survival was calculated using Kaplan–Meier curves with log-rank tests for significance.

Results

We identified 45 patients with T4 tumors all who underwent NT. The median age was 60 years (range, 31–79 years) with a median follow-up of 27 months (range, 0–122 months). There were 19 pCR (42 %), 22 pPR (49 %), and 4 NR (9 %). R0 resections were accomplished in 43 (96 %). There were 18 recurrences (40 %) with a median time to recurrence of 13.5 months (2.2–71 months). In this group pCR represented 7 (38.9 %), whereas pPR and NR represented 10 (55.5 %), and 1 (5.5 %) respectively. The overall and disease-free survival for all patients with T4 tumors were 35 and 36 %, respectively. Patients achieving a pCR had a 5 year overall and disease-free survival of 53 and 54 %, compared with pPR 23 and 28 %, while there were no 5 year survivors in the NR cohort.

Conclusion

We have demonstrated that neoadjuvant therapy and downstaging of T4 tumors leads to increased R0 resections and improvements in overall and disease-free survival.     

Assessing the Costs Associated with Volume-Based Referral for Hepatic Surgery

Background

Although proposed as a means for quality improvement, little is known regarding the economic consequences of volume-based referral. The objective of the current study was to investigate the relationship between inpatient costs and hospital volume.

Methods

Patients undergoing elective liver surgery were identified using the Nationwide Inpatient Sample from 2001 to 2012. Multivariable hierarchical regression analyses were performed to calculate and compare risk-adjusted costs and postoperative outcomes across hospital volume terciles.

Results

A total of 27,813 patients underwent surgery at 2207 hospitals. Although costs were comparable across the three volume groups (all p?>?0.05), patients who developed a postoperative complication incurred a higher overall cost (complication vs. no complication; median costs $17,974 [IQR 13,865–25,623] vs. $41,731 [IQR 27,008–64,266], p?<?0.001). In contrast, while the incidence of postoperative complications (low vs. intermediate vs. high; 22.0 vs. 19.2 vs. 13.0 %, p?<?0.001) and subsequent failure-to-rescue (low vs. intermediate vs. high; 16.6 vs. 24.7 vs. 15.1 %, p?<?0.001) was lower at high-volume hospitals, costs associated with “rescue” were substantially higher at high-volume hospitals (low vs. intermediate vs. high; $39,289 vs. $36,157 vs. $48,559, both p?<?0.001).

Conclusions

Compared with lower volume hospitals, improved outcomes among patients who developed a complication at high-volume hospitals were associated with an increased cost.

     

Factors Associated with Biochemical Remission after Microscopic Transsphenoidal Surgery for Acromegaly

Objectives To analyze surgical outcomes and predictive factors of disease remission in acromegaly patients who underwent microscopic transsphenoidal surgery (TSS) for a growth hormone (GH)-secreting adenoma. Design A 6-year retrospective review of 86 consecutive acromegaly surgeries. Setting Procedures performed at a single institution by a single surgeon. Participants Seventy acromegaly patients. Main Outcome Measures Demographic information, preoperative laboratory values, tumor imaging data, and morphological and immunohistochemical data were collected. Predictive values using the latest and most stringent biochemical remission criteria were determined using univariate and multivariate statistical analyses. Results Remission rate for 59 (18 males) acromegaly patients meeting the study inclusion criteria was 52.5%. Remission rates for micro- and macroadenomas were 81.8% and 45.8%, respectively. Patients of older age, with a smaller tumor, lower Knosp grade, lower preoperative GH, and insulinlike growth factor 1 levels were more likely to achieve remission. Remission rate decreased significantly with repeat surgeries. Those patients with adenomas that stained positive for somatostatin receptor subtype 2A were less likely to experience tumor recurrence and more likely to respond to medical treatment with persistent or elevated GH hypersecretion. Conclusions Microscopic TSS continues to be a viable means for treating acromegaly patients. Patients should be followed long term.     

The Medical Malpractice Risk Associated with Bariatric Surgery

Background: Bariatric surgery has been classified as high risk by the medical malpractice industry, but it is unclear what data support this classification. When a small group of physicians is separated from their peers and asked to support their malpractice claims, their premiums will often rise unfairly in relation to the outcome of the claims. This report outlines the results of a survey sent to the members of the American Society for Bariatric Surgery (ASBS) asking for information on malpractice claims. Methods: Surveys were mailed to the 285 ASBS members requesting which bariatric operations were performed, how many procedures were completed each year, details of any suits filed against the member including final outcome, and information on whether the members also performed gastric surgery for ulcer disease. Results: Surveys were returned by 165 members (58%) from surgeons in 33 states and Washington, D.C. Malpractice claims had been made after 107 bariatric procedures and three ulcer procedures with the risk of a suit being filed for a bariatric procedure being approximately 1.6/1,000 cases. The average monetary award was $88,667. Of the suits that resulted in a jury trial, 14% agreed with the plaintiff. Over half the cases that had been resolved were either dropped or dismissed before trial. Conclusions: The incidence of suit being brought against ASBS members performing bariatric procedures is low. Once filed, most cases do not reach a jury trial. Settlements are usually under $100,000. These data suggest that this group of bariatric surgeons do not represent a disproportionately large risk pool for medical malpractice insurance companies.     

肝癌伴肝硬化、脾功能亢进一期手术治疗体会

目的探讨肝癌合并肝硬化、脾功能亢进一期手术治疗的临床疗效。方法对2002年1月至2005年10月我院手术治疗的36例肝癌合并肝硬化、脾功能亢进患者的临床资料进行回顾性分析。结果36例患者行肝脏癌肿切除,联合脾切除一期手术。术后1例患者因肝功能衰竭死亡,35例患者恢复顺利,脾功能亢进全部消失,无严重手术并发症。结论对肝癌合并肝硬化、脾功能亢进患者采用肝脏癌肿切除联合脾切除一期手术是安全可行的。围手术期的处理是提高患者远期疗效的关键。     

Risk Factors Associated with In-Hospital Mortality for Patients with Acute Abdomen After Cardiac Surgery

World Journal of Surgery - Management of acute abdomen (AA) differs due to the heterogeneity of underlying pathophysiology. Complications of AA and its overall outcome after cardiac surgery are...     

Factors Associated with Recurrence Within 2 Years After Curative Surgery for Gastric Adenocarcinoma

Background

Despite curative surgery for gastric cancer, many patients die of recurrent cancer. Few studies have investigated the time to recurrence after curative resection for gastric cancer.

Methods

Data were collected prospectively between December 1987 and December 2006. A total of 1,549 patients underwent curative resection of adenocarcinoma of the stomach at Taipei Veterans General Hospital. Among them, 419 patients had recurrence; they were divided into early recurrence (<2?years) and late recurrence (??2?years). The clinicopathological characteristics, survival time after recurrence, and recurrence patterns were compared between the two groups.

Results

Multivariate analysis showed that stage III gastric cancer patients with early recurrence had larger tumors and more lymph node metastasis than patients with late recurrence, while no difference between early and late recurrence was observed in stage I and II patients. Early recurrence was associated with more distant metastasis than was late recurrence. Patients with advanced TNM stage tended to die within 2?years after recurrence.

Conclusions

Gastric cancer patients with larger tumors and more lymph node metastasis tended to have early recurrence, especially stage III patients. Advanced TNM stage was associated with early cancer death after recurrence.     

Morbidity Associated with Concomitant Thyroid Surgery in Patients with Primary Hyperparathyroidism

Annals of Surgical Oncology - Recurrent laryngeal nerve (RLN) palsy and hypoparathyroidism are serious complications in thyroid and parathyroid surgery. The extent to which incidentally detected...     

Morbidity Associated with Colostomy Reversal After Cytoreductive Surgery and HIPEC

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved the survival in selected colorectal cancer patients with peritoneal metastases. In these patients, the risk of a low anastomosis is sometimes diminished through the creation of a colostomy. Currently, the morbidity and mortality associated with the reversal of the colostomy in this population is unknown.

Methods

Our study involved two prospectively collected databases including all patients who underwent CRS–HIPEC. We identified all consecutive patients who had a colostomy and requested a reversal. The associations between four clinical and ten treatment-related factors with the outcome of the reversal procedure were determined by univariate analysis.

Results

21 of 336 patients (6.3 %) with a stoma with a mean age of 50.8 (standard deviation 10.2) years underwent a reversal procedure. One patient was classified as American Society of Anesthesiologists (ASA) grade III, 6 as ASA grade II, and the remaining as ASA grade I. Median time elapsed between HIPEC and reversal was 394 days (range 133–1194 days). No life-threatening complications or mortality were observed after reversal. The reversal-related morbidity was 67 %. Infectious complications were observed in 7 patients (33 %). Infectious complications after HIPEC were negatively correlated with the ultimate restoration of bowel continuity (P = 0.05). Bowel continuity was successfully restored in 71 % of the patients.

Conclusions

Although the restoration of bowel continuity after CRS–HIPEC was successful in most patients, a relatively high complication rate was observed. Patients with infectious complications after HIPEC have a diminished chance of successful restoration of bowel continuity.     

Unplanned Robotic-Assisted Conversion-to-Open Colorectal Surgery is Associated with Adverse Outcomes

Background

Laparoscopic conversion-to-open colorectal surgery is associated with worse outcomes when compared to operations completed without conversion. Consequences of robotic conversion have not yet been determined. The purpose of this study is to compare short-term outcomes of converted robotic colorectal cases with those that are completed without conversion, as well as with cases done by the open approach.

Methods

The ACS-NSQIP database was queried for patients who underwent robotic completed, robotic converted-to-open, and open colorectal resection between 2012 and 2015. Propensity scores were estimated using gradient-boosted machines and converted to weights. Generalized linear models were fit using propensity score-weighted data.

Results

A total of 25,253 patients met inclusion criteria—21,356 (84.5%) open, 3663 (14.5%) robotic completed, and 234 (0.9%) conversions. Conversion rate was 6.0%. Converted cases had significantly higher 30-day mortality rate, higher complication rate, and longer hospital length of stay than completed cases. Converted patients also had significantly higher rates of the following complications: surgical site infections, cardiac complications, deep venous thrombosis, postoperative ileus, postoperative re-intubation, renal failure, and 30-day reoperation. Compared to the open approach, converted patients had significantly more cardiac complications, postoperative reintubation, and longer operating times with no significant difference in 30-day mortality.

Conclusions

Unplanned robotic conversion-to-open is associated with worse outcomes than completed cases and outcomes that more closely resemble traditional open colorectal surgery. Patients should be counseled with regard to minimally invasive conversion rates and outcomes. The continued pursuit of technological advancements that decrease the risk for conversion in minimally invasive colorectal surgery is clearly warranted.

     

Incidence and Factors Associated with Recurrence Patterns after Intended Curative Surgery for Gastric Cancer

Abstract Recurrence after curative resection for gastric cancer remains high. We examined its incidence and factors related to recurrence pattern, while trying to avoid the interaction of various factors. A total of 611 gastric cancer patients after resection for curative intent (1988–1995) were analyzed. The result showed that 245 patients had recurrence (40.1%). Cumulative recurrence rates were 53.5%, 80%, 89.0%, 94.7%, 96.3%, 98%, and 99.5% at 1, 2, 3, 4, 5, 6, and 7 years, respectively. Over half of patients with recurrence (123; 50.2%) had an initial single recurrence. Taking single and multiple recurrence together, most recurrences (213; 86.9%) were distant metastases, 110 recurrences (44.9%) were local relapses, and 78 recurrences (49.8%) were both local and distant. Among the distant metastases, 131 patients (53.5%) had peritoneal dissemination, 106 patients (43.3%) had hematogenous metastases, and 70 patients (28.6%) had distant lymphatic spread. Scirrhous-type stromal reaction, serosa invasion, and female gender were factors negatively related to peritoneal recurrence. Medullary-type stromal reaction and male gender showed a preference for locoregional recurrence, and expanding growth tumor commonly led to hematogenous metastasis. Patients who had paraaortic lymph node metastasis were at high risk of developing distant lymphatic recurrence. It is conceivable that the patterns of recurrence and the times to recurrence provide a biological basis for clinical monitoring of patients with the aim of modifying therapeutic modalities.     

Changing Indications for Pacemakers in Children

Permanent pacemakers were implanted in 50 children. Indications were symptomatic sinus node dysfunction in 34 (68%), surgical block in 9 (18%), and congenital block in 7 (14%). Twenty-three (68%) of the 34 children with sinus node dysfunction had undergone prior cardiac operations.Only 4 of the 50 patients (8%) had electrode problems after a mean pacing time of 29.5 months (range, 1 to 96 months). All 35 of the mercury-cell pulse generators used in 28 patients ceased to function after an average useful life of 20.8 months (range, 1 to 51 months). The lithium-powered units in the 45 survivors all show satisfactory pacing after 5 to 44 months (mean, 28.1 months).With improved pacemaker technology, longer survival after complex repairs, and better monitoring techniques, the indications for cardiac pacing in children have broadened. Surgical block now is an indication in only a small fraction of the pediatric pacemaker population. Sinus node dysfunction accounts for an ever-increasing majority of the pacemakers we currently implant in children.