Repair of Symptomatic Giant Paraesophageal Hernias in Elderly (>70 Years) Patients Results in Improved Quality of Life

Introduction  

Giant paraesophageal hernias (PEH) involve herniation ofstomach and/or other viscera into the mediastinum. These are usually symptomatic and commonly occur in the elderly. The benefits and risks of operating on elderly patients with giant PEH have not been clearly elucidated.     

Uncemented Total Hip Arthroplasty Using a Tapered Femoral Component in Obese Patients: An 18–27 Year Follow-Up Study

The purpose of this study was to evaluate the efficacy of an uncemented tapered femoral component in obese patients at a mean follow-up of 23 years. We retrospectively reviewed 119 consecutive uncemented total hip arthroplasties in 105 obese patients using a tapered femoral component between 1983 and 1987. The mean body mass index of these patients was 34 (range 30–47). Complete clinical and radiographic follow-up was obtained on the 55 hips in 47 patients who survived a minimum of 18 years (range 18–27 years). Three femoral components (6%) have been revised, none for aseptic loosening. One was loose by radiographic criteria. These results demonstrate that an uncemented tapered stem can provide excellent fixation in obese patients out to 27 years.     

Presentation and Survival of Operable Esophageal Cancer in Patients 55 Years of Age and Below

Background  

The increased incidence of esophageal cancer, especially in the younger age group, should encourage early diagnosis. The perceived rarity and poor prognostic outcome of esophageal cancer in this group is based on retrospective studies. The goal of this study was to review the presentation and survival of young patients with esophageal cancer.     

Do “Premium” Joint Implants Add Value?: Analysis of High Cost Joint Implants in a Community Registry

Background  

Numerous joint implant options of varying cost are available to the surgeon, but it is unclear whether more costly implants add value in terms of function or longevity.     

Nipple-Sparing Mastectomy in 99 Patients With a Mean Follow-up of 5 Years

Background

The safety and practicality of nipple-sparing mastectomy (NSM) are controversial.

Methods

Review of a large breast center’s experience identified 99 women who underwent intended NSM with subareolar biopsy and breast reconstruction for primary breast cancer. Outcome was assessed by biopsy status, postoperative nipple necrosis or removal, cancer recurrence, and cancer-specific death.

Results

NSM was attempted for invasive cancer (64 breasts, 24 with positive lymph nodes), noninvasive cancer (35 breasts), and/or contralateral prophylaxis (50 breasts). Twenty-two nipples (14%) were removed because of positive subareolar biopsy results (frozen or permanent section). Seven patients underwent a pre-NSM surgical delay procedure because of increased risk for nipple necrosis. Reconstruction used transverse rectus abdominis myocutaneous flaps (56 breasts), latissimus flaps with expander (35 breasts), or expander alone (58 breasts). Of 127 retained nipples, 8 (6%) became necrotic and 2 others (2%) were removed at patient request. There was no nipple necrosis when NSM was performed after a surgical delay procedure. At a mean follow-up of 60.2 months, all 3 patients with recurrence had biopsy-proven subareolar disease and had undergone nipple removal at original mastectomy. There were no deaths.

Conclusions

Five-year recurrence rate is low when NSM margins (frozen section and permanent) are negative. Nipple necrosis can be minimized by incisions that maximize perfusion of surrounding skin and by avoiding long flaps. A premastectomy surgical delay procedure improves nipple survival in high-risk patients. NSM can be performed safely with all types of breast reconstruction.     

Comparable Cumulative Incidence of Late Periprosthetic Femoral Fracture and Aseptic Stem Loosening in Uncemented Total Hip Arthroplasty—A Concise Follow-Up Report at a Minimum of 20 Years

Background

There is a lack of long-term studies into the third decade reporting on the incidence of periprosthetic femoral fracture (PPFF) and aseptic stem loosening (ASL) after cementless total hip arthroplasty (THA). The aim of the present retrospective, longitudinal cohort study was to compare the cumulative incidence of PPFF and ASL in a consecutive cohort of 326 patients with 354 primary uncemented THAs after 20-25 years and to identify risk factors being associated with PPFFs.

Outcomes of Robot-Assisted Pancreaticoduodenectomy in Patients Older Than 70 Years: A Comparative Study

Background

Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures and its application in the elderly population is poorly reported in the literature so far. The goal of this study was to demonstrate that robot-assisted PD can be safely performed in patients aged 70 years and older.

Methods

Forty-one consecutive robot-assisted PD performed between April 2007 and January 2010 were prospectively entered in a dedicated database. Patients were stratified into two groups: group 1, aged ≥70 years (n = 15, 36.6%); and group 2, aged <70 years (n = 26, 63.4%). The data were reviewed retrospectively.

Results

Indications for surgery and patient characteristics were the same in both groups, with the exception of age. There was no statistical difference in terms of operative time (P = 0.376), blood loss (P = 0.989), conversion rate (P = 0.52), mortality (P = 0.36), or overall morbidity rate (P = 0.74). The mean hospital stay was 14.3 days in group 1 and 11.2 days in group 2. This was not statistically significant (P = 0.136).

Conclusions

Robot-assisted pancreaticoduodenectomy can be performed safely in elderly patients with comparable mortality, morbidity, and outcomes compared with a younger population. Age alone should not be a contraindication for robotic pancreatic resection.     

Postoperative Complications and Survival after Gastric Cancer Surgery in Patients Older than 80 Years of Age

Background

This study sought to identify and evaluate the risk factors of postoperative complications, prognostic factors, and appropriate surgical strategies in elderly patients undergoing surgery for gastric cancer.

Methods

The medical records of 396 radical gastrectomies conducted from January 2006 to December 2011 were retrospectively reviewed. Surgical results and survival rates were assessed for 60 elderly patients (aged?≥?80 years) and 336 non-elderly patients (aged?<?80 years). The study groups were compared with respect to clinicopathological findings, surgical outcomes, and survival.

Results

Elderly patients underwent gastrectomies with shorter operation time, showed less extensive lymphadenectomy, and had a significant difference in overall survival compared with non-elderly patients, although there was no difference in cause-specific survival among patients receiving curative resection. No significant risk factors affecting postoperative complications were identified in the elderly patients. Number of comorbidities (≥2) (HR, 5.30; 95 % CI, 1.11–25.32; P?=?0.037) and TNM stage (≥II) (HR, 12.97; 95 % CI, 1.60–105.38; P?=?0.017) were identified as independent prognostic factors in the elderly patients receiving curative resection.

Conclusions

Age is not an independent prognostic factor for patients receiving curative resection for gastric cancer. Multiple comorbidities may also influence the prognosis of elderly patients. Careful follow-up would improve overall survival for elderly patients.     

Intramedullary versus Extramedullary Tibial Cutting Guide in Severely Obese Patients Undergoing Total Knee Replacement: A Randomized Study of 70 Patients with Body Mass Index >35 kg/m<Superscript>2</Superscript>

Background  Patients with obesity have an increased risk of osteoarthritis of the knee, which can lead to the need for total knee replacement (TKR). TKR may be more complex in obese patients and the correct orientation of the implant is more difficult. We selected patients with body mass index (BMI) >35 kg/m² undergoing TKR and studied the utility of an intramedullary tibial cutting guide in facilitating the correct orientation of the tibial implant. Methods  Seventy patients with BMI >35 kg/m² were selected for a prospective, randomized study. Patients were divided into two groups: In group 1 (n = 31), the tibial component was implanted using the aid of a intramedullary tibial guide. In group 2 (n = 39), the tibial component was implanted using the aid of an extramedullary tibial cutting guide. Results  The two groups were comparable with respect to age, BMI, and degree of preoperative deformity. Mean age was 69.35 in group 1 and 70.06 in group 2. Group 1 had a mean BMI of 39.84 kg/m² and group 2 of 40.05 kg/m². Postoperative orientation of the femur and tibia and the mechanical axis were within the normal range in both groups. A statistically significant difference between the two groups was observed in tourniquet time, which was longer in group 2 than in group 1 (p = 0.038). Conclusion  Two types of guide were compared in correctly orienting the tibial component of the TKR in patients with a BMI >35 kg/m². The lesser tourniquet time in the group in which the intramedullary guide was used suggest its usefulness because the positioning and orientation of the tibial cut was carried out more rapidly and anatomical references were not needed for correct orientation, as it is guided by the anatomical axis of the tibia. The use of the intramedullary guide reduces surgical time in these patients.     

Long-Term Outcomes of Ultra-Short Metaphyseal-Fitting Anatomic Cementless Femoral Stem in Total Hip Arthroplasty With Ceramic-on-Ceramic Articulation for Young Patients

BackgroundThe aim of this study is to assess the long-term outcomes of this specific stem in patients younger than 50 years old, with regard to clinical and radiographic outcomes, survivorship, and complication rate.MethodsTwo hundred thirty-nine consecutive series of patients (324 hips) who were younger than 50 years old at the time of surgery were enrolled in the study. Osteonecrosis (50%) and dysplastic hip (34%) were most common diagnoses. Patients were informed to use crutches or walker for 4 weeks to protect the femoral component against rotational stress. The mean follow-up was 15.6 years (range 14-17).ResultsAt the latest follow-up, the mean Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index score, and University of California, Los Angeles activity score were 93 points, 13 points, and 7 points, respectively. Three patients (1.3%) had moderate thigh pain. All of the acetabular components and 321 (99%) femoral stems were solidly fixed at the time of the latest follow-up. Three stems (0.9%) were revised for aseptic loosening. Two hips (0.6%) had a dislocation and 2 hips (0.6%) had a periprosthetic fracture. Ceramic fracture or osteolysis was not found in any hip at the time of the final follow-up. Survival rate of the femoral component was 99.1% (95% confidence interval 94-100) and that of the acetabular component was 100% (95% confidence interval 94-100) at 15.6 years.ConclusionIn this series, THA using an ultra-short metaphyseal-fitting anatomic cementless femoral stem provided excellent long-term clinical and radiographic results in patients younger than 50 years old. Furthermore, our initial theoretical concerns about early aseptic loosening due to the absence of distal stem fixation were not justified.     

Is Age Trumping Genetic Profiling in Clinical Practice? Relationship of Chemotherapy Recommendation and Oncotype DX Recurrence Score in Patients Aged &lt; 50 Years versus ≥ 50 Years,and Trends Over Time

Background

Oncotype DX (oDX) is used to predict recurrence and indicate response to chemotherapy in patients with early-stage breast cancer (BC). We evaluated the relationship between age (<?50 vs.?≥?50 years), recurrence score (RS), chemotherapy use, and trends of oDX testing over time.

Methods

Using the National Cancer Database, we identified women with T1/T2, N0, estrogen receptor-positive BC from 2009 to 2014. We stratified patients by age (<?50 and?≥?50 years) and RS (low: <?18; intermediate: 18–30; and high: >?30), and compared demographics, tumor characteristics, and chemotherapy recommendations. Management trends were also assessed.

Results

From 2009 to 2014, a total of 377,725 cases met the eligibility criteria for oDX testing; 115,052 (30.5%) patients had oDX, and 60,804 (16.1%) were <?50 years of age. The majority had low RS and T1N0 disease. Patients <?50 years of age were more likely to be recommended chemotherapy than those ≥?50 years of age, regardless of RS (p?≤?0.001), and were more likely to ultimately undergo chemotherapy (p?<?0.001). When stratified by year, oDX utilization increased. There was a decreasing trend in chemotherapy recommendations in both the low- and intermediate-RS groups for both age groups (all p?=?0.001), with no change in the high-RS group (<?50 years: p?=?0.52;?≥?50 years: p?=?0.67). Univariate and multivariate analyses demonstrated that patients?<?50 years of age and those with a higher RS were more likely to be recommended chemotherapy (p?<?0.001).

Conclusions

The testing of oDX in BC has significantly increased since first implemented. Results from additional studies such as TAILORx will clarify the current discordant practice patterns between low oDX RSs and adjuvant chemotherapy recommendations.

     

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure has shown to be effective in achieving significant weight loss and resolving obesity-related co-morbidities. However, its nutrition consequences have not been extensively explored. This study aims to investigate weight loss and evolution of nutritional deficiencies in a group of patients 3 years post LSG.

Methods

Retrospective data of a group of patients, 3 years following LSG as a stand-alone procedure was collected. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B₁₂), and compliancy with supplementations.

Results

Ninety-one patients (male/female; 28:63), aged 51.9?±?11.4 years with a BMI of 42.8?±?6.1 kg/m² were identified to be 3 years post LSG. Percentage of weight loss at 1 and 3 years post-operatively was 29.8?±?7.0 and 25.9?±?8.8 %, respectively. Pre-operatively, the abnormalities included low hemoglobin (4 %), ferritin (6 %), vitamin B₁₂ (1 %), vitamin D (46 %), and elevated iPTH (25 %). At 3 years post-operatively, the abnormal laboratory values included low hemoglobin (14 % females, P?=?0.021), ferritin (24 %, P?=?0.011), vitamin D (20 %, P?=?0.018), and elevated iPTH (17 %, P?=?0.010). Compliancy with multivitamin supplementation was noted in 66 % of patients.

Conclusion

In these patients, LSG resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies are prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

     

Validation of a Food-Frequency Questionnaire for the Assessment of Calcium Intake in Schoolchildren Aged 9–10 Years

Bone mass increases steadily until age 20–30 years, when peak bone mass (PBM) is acquired. Nutrition plays a critical role in achievement of the optimal genetically programmed PBM, with reduction in the risk of osteoporosis later in life. Intake of nutrients can be estimated through the use of various tools; typically, food-frequency questionnaires (FFQs) are used in epidemiologic studies. The aim of this study was to validate a 21-item, semiquantitative FFQ to assess important nutrient intakes for bone health in Italian schoolchildren 9–10 years of age. Relative validation was accomplished through comparison of the 7-days weighed food record (7D records) with an FFQ developed ad hoc, completed by a group of 75 Italian schoolchildren (36 females, 39 males). Agreement between the two methods was evaluated by Spearman’s correlation test and Bland–Altman analysis applied on the data on intake of energy, macronutrients, and micronutrients. Particular attention was devoted to nutrients relevant for bone health. Good correlations between the two methods (FFQ and 7D records) were observed for all nutrients. In particular, mean dietary calcium intakes were 725.6 mg/day (95 % CI 683.2–768.1) from 7D records and 892.4 mg/day (95 % CI 844.6–940.2) from the FFQ. These results indicate that our FFQ for schoolchildren aged 9–10 years is highly acceptable as it is an accurate method that can be used in large-scale or epidemiological studies for the evaluation of nutrient intakes important for the prevention of osteoporosis in a similar population.     

Displaced Femoral Neck Fractures in Workers’ Compensation Patients Aged 45-65 Years: Is It Best to Fix the Fracture or Replace the Joint?

BackgroundOptimal surgical management of displaced femoral neck fractures (dFNFs) in subjects 45-65 years old is unclear. We evaluated days out of work (dOOW), medical and indemnity costs, and secondary outcomes at 2 years between internal fixation (IF), hemiarthroplasty (HA), and total hip arthroplasty (THA) among workers’ compensation (WC) subjects with isolated dFNFs aged 45-65.MethodsWe retrospectively identified 105 Ohio Bureau of WC subjects with isolated subcapital dFNFs aged 45-65 with 2 years of follow-up. In total, 37 (35.2%) underwent IF, 23 (21.9%) THA, and 45 (42.9%) HA from 1993 to 2017. Linear regression was used to determine if surgery type was predictive of dOOW postoperatively and to evaluate inflation-adjusted net medical and indemnity costs at 2 years.ResultsIF subjects were younger (52.9) than THA (58.5, P < .001) and HA (58.4, P < .001) subjects. Mean dOOW for THA subjects at 6 months, 1 year, and 2 years was 90.8, 114.6, and 136.6. This was significantly lower than IF (136.3, 182.0, 236.6) and HA (114.6, 153.3, 247.6) subjects at all time points. Medical costs were similar. Mean indemnity costs were 3.0 and 2.4 times higher among IF (P < .001) and HA (P = .007) groups compared to THA, respectively. Rates of postoperative permanent disability awards were 13.0%, 43.2%, and 35.6% for the THA, IF, and HA groups (P = .050). IF and HA subjects had a 24.3% and 11.1% revision rate. Overall, 77.8% and 100% of the IF and HA revisions were conversions to THA.ConclusionWC subjects aged 45-65 with dFNFs treated with THA had fewer dOOW, lower indemnity costs, and less disability at 2 years. Longer follow-up will help determine the durability and long-term outcomes of these surgeries.