Esophagectomy in the state of Florida: is regionalization of care warranted?

Centralization of cancer care needs to be based on evidence that regionalization will improve outcomes in a given region. We analyzed outcomes for esophagectomy performed in Florida using the Agency for Health Care Administration database. We determined the risk-adjusted mortality rate for the procedure in low-volume and high-volume centers. From 1997 to 2006, 991 esophagectomies were performed in Florida. The incidence of esophagectomy significantly increased from 1997 to 2001 compared with 2002 to 2006, and the postoperative mortality decreased in the latter time period (odds ratio [OR], 1.87; confidence interval [CI], 1.16-3.03). The risk-adjusted postoperative mortality was significantly lower (OR, 0.54; CI, 0.32-0.92) in high-volume centers (5.1 vs 10.4%). The anastomotic leak rates were 8.2 per cent in both high- and low-volume centers. In the largest population-based study for esophagectomy in Florida, outcomes are better in high-volume centers. These data support the regionalization of esophagectomy to high-volume locations in Florida to reduce procedure-related mortality.     

A trial of Biolite ventilation tubes in children: is further use warranted?

A prospective controlled pilot study was undertaken in which Biolite (carbon-coated) ventilation tubes were placed in 44 ears and a conventional silicone tube in the contralateral ear. Long-term follow-up of these patients has revealed little difference in the incidence of tube occlusion or early extrusion. In addition, there were several disadvantages noted with the Biolite tubes: incomplete coating of the tube (especially within the lumen), shedding of the Biolite coating over time, "tattooing" of the tympanic membrane, poor otoscopic visibility, and the higher cost of these tubes. Since the Biolite tube has no documented advantages and, actually, several disadvantages, we believe its use in the treatment of middle ear disorders should be discontinued until significant benefits are demonstrated and present deficiencies are corrected.     

Blunt liver injury in children and adults: is there really a difference?

Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (> or = 18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.     

Treatment of perforated appendicitis in children: what is the cost?

Background/PurposeWe compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children.MethodsFrom June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy.ResultsPatients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies.ConclusionsPatients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.     

Traumatic rupture of the urinary bladder: is the suprapubic tube necessary?

BACKGROUND: Although surgical principles are well accepted for the treatment of an intraperitoneal or extraperitoneal rupture of the urinary bladder, the type and number of drainage catheters needed to obtain a satisfactory outcome with minimal patient morbidity have yet to be determined. METHODS: This was a retrospective review of data on injured patients with the diagnosis of an intraperitoneal or extraperitoneal rupture of the urinary bladder from penetrating or blunt trauma. RESULTS: Of the 51 patients identified, 28 were treated with suprapubic and transurethral catheters, whereas 23 received a transurethral catheter only. Complications and catheter duration times were similar regardless of type of bladder injury or drainage catheter used (p > 0.5). CONCLUSION: These data suggest that there are similar outcomes and complication rates for patients treated with suprapubic and transurethral catheters versus transurethral catheter only. Transurethral catheters alone seem effective in draining all types of bladder injuries.     

Multifocal hepatoblastoma: What is the risk of recurrent disease in the remnant liver?

PurposeMultifocal hepatoblastoma (HB) is often treated with total hepatectomy and transplantation owing to concerns of surgical resectability, local recurrence, and/or metachronous tumor in the remnant liver. We aimed to review HB patients to determine the risk of local recurrence in multifocal disease.MethodsWe undertook retrospective cohort analysis of all HB patients at a single tertiary referral center between 2001 and 2015. Demographics, diagnostic features, operative details, and outcomes were analyzed.ResultsSixty patients underwent surgical management of HB. 39 had unifocal, and 21 had multifocal disease. Of multifocal patients, 9 underwent liver transplantation, 10 anatomic resections, and 2 nonanatomic resections. Overall, two patients had recurrence in the remnant liver — both from the unifocal group. There were equivalent distant (lung) recurrences between the groups (8% for unifocal versus 14% for multifocal), p = 0.89. At a mean of 75 months of follow-up, overall survival was 97% for unifocal patients and 86% for multifocal patients, p = 0.12.ConclusionMultifocal HB was not associated with increased local recurrence in the setting of R0 resection and chemotherapy. These data do not support the contention that all patients with multifocal HB require a total hepatectomy and transplantation to reduce the incidence of local recurrence and/or metachronous tumor development.Level of evidenceLevel III — Limited cohort analysis.     

Axillary recurrence in DCIs: is axillary lymphadenectomy warranted?

Widespread use of screening mammography has resulted in a remarkable increase in the incidence (or detection rate) of ductal carcinoma in situ (DCIS). Axillary lymph node involvement in DCIS is reported to occur at a frequency of 1-12 per cent. Over the past few years, however, there has been increasing emphasis on axillary sampling, limited axillary dissection, and the potential role of sentinel lymph node biopsy. The clinical relevance of axillary lymph node biopsy or dissection remains unanswered. This retrospective analysis was performed on 171 patients who underwent treatment for DCIS at a tertiary care center over a period of 14 years. Clinical and tumor factors were evaluated, and the local, axillary, and systemic recurrence rates were noted. No axillary recurrences from the primary DCIS diagnosis were noted in the entire group of 171 patients. During a mean follow-up of 70 months, 10 patients (6%) developed recurrence in the ipsilateral breast. Six of these recurrences were in the form of DCIS, whereas, four recurred as invasive cancers. Nine patients developed a new primary (seven DCIS and two invasive) in the same breast but in a different quadrant. Two patients with ipsilateral invasive disease also developed systemic disease and eventually died of disease. During the same period, 10 patients (6%) developed DCIS, and seven patients (4%) developed invasive cancer in the contralateral breast. The data show that the risk of axillary recurrence in pure DCIS is, at most, extremely low and support the position that nodal sampling or dissection is unwarranted.     

The epidemic of ankle fractures in the elderly – is surgical treatment warranted?

Ankle fractures in the elderly are extremely common (up to 184 fractures per 100,000 persons per year, and of these approximately 20%–30% occur in the elderly). The medical literature contains no research that has investigated ankle fractures in the elderly. A prospective, randomised study was conducted of 84 patients with displaced ankle fractures, who were over the age of 65 years and were assigned to operative or conservative treatment after closed reduction. The results of treatment assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) Score showed a mean of 91.37 ± 8.96 in the non-operated group compared with 75.2 ± 14.38 (P = 0.001) in the operated group. The costs of treatment were accordingly higher. These results call for consideration of a non-operative approach to the treatment of well-reduced ankle fractures in the elderly. Increased efforts should be invested in the prevention of these common fractures.

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Received: 29 November 1999     

What is new in liver surgery? Focus on thermoablation and the relevance of the inflammatory response

Partial liver resection is a well established treatment for patients with liver tumors. It is associated with significant morbidity and some mortality, even in high volume centers. Less invasive modalities are currently available and deserve a place in the armamentarium of liver surgeons. This review discusses the role of thermoablation as a treatment modality for liver tumors. The minimal invasive possibility of percutaneous ablation is a great advantage. The limitation of ablation is the high incidence of ablation site recurrences. The inflammatory response is associated with the initiation of cancer at sites of chronic inflammation. There is also accumulating evidence that progression of tumors is also enhanced by an ongoing inflammatory response. The common denominator probably is angiogenesis. The paper supplies data about the interrelationship between inflammation, angiogenesis and tumor growth. Ablation of liver tumors is associated with a low inflammatory response, especially if it is performed percutaneous and thus deserves to be considered in patients with liver tumors.     

Diagnosis and staging of malignant bone tumours in children: what is due and what is new?

PurposeAlthough malignant bone tumours in children are infrequent, it is important to know how to properly diagnose and stage them, in order to establish an adequate treatment.MethodsWe present a review of the diagnostic workflow of malignant bone tumours in children, including history and clinical examination, imaging, laboratory tests and biopsy techniques. Moreover, the two most commonly used staging systems are reviewed.ResultsHistory, clinical examination and laboratory tests are nonspecific for diagnosing malignant bone tumours in children. Radiographs remain the mainstay for initial diagnosis, with MRI the modality of choice for local assessment and staging. Fluorine-18 labelled fluoro-deoxy-glucose-positron emission tomography scans provide a noninvasive method to assess the aggressiveness of the tumour and to rule out metastasis and is replacing the use of the bone scintigraphy. Biopsy must be always performed under the direction of the surgeon who is to perform the surgical treatment and after all diagnostic evaluation has been done. Staging systems are useful to study the extent of the tumour and its prognosis. They are expected to evolve as we better understand new molecular and genetic findings.ConclusionWhen a malignant bone tumour is suspected in a child, it is essential to make a correct diagnosis and referral to an experienced centre. Following an appropriate workflow for diagnosis and staging facilitates, prompt access to treatment improves outcomes.Level of EvidenceLevel V Expert opinion     

Evaluation of routine tracheal extubation in children: inflating or suctioning technique?

We studied prospectively the effects of the technique of tracheal extubation on arterial haemoglobin oxygen saturation (SpO2) in 120 ASA I-III children, mean age 5.3 (range 0.25-16.9) yr. At completion of surgery, tracheal extubation was performed when spontaneous ventilation had resumed, children were fully awake and SpO2 was 99-100%. Children were allocated randomly to receive a single lung inflation manoeuvre with 100% oxygen before tracheal extubation (group I; n = 59) or to have the tracheal tube removed while applying suction through the tube (group S; n = 61). SpO2 was monitored during the first 5 min after tracheal extubation in the operating room. Supplementary oxygen was given if SpO2 decreased to less than 92%. The time between tracheal extubation and decrease in SpO2 to 92% (T92) was recorded. Children in group S required oxygen administration more frequently after tracheal extubation than those in group I (65.6% vs 45.8%; P = 0.04), and had a three-fold shortening of T92 (mean 25 (SD 19) s vs 85 (63) s; P = 0.0001). These effects were more pronounced in children less than 4 yr of age compared with older children. We conclude that tracheal extubation greatly impaired oxygenation and therefore administration of oxygen was appropriate. This impairment was more marked when suction was used, and in young children. Lung inflation with 100% oxygen before removal of the tracheal tube is advised before routine tracheal extubation in children.      

Vitamin K supplementation for the primary prevention of osteoporotic fractures: is it cost-effective and is future research warranted?

Summary

Lifetime supplementation with vitamin K, vitamin D₃, and calcium is likely to reduce fractures and increase survival in postmenopausal women. It would be a cost-effective intervention at commonly used thresholds, but high uncertainty around the cost-effectiveness estimates persists. Further research on the effect of vitamin K on fractures is warranted.

Introduction

Vitamin K might have a role in the primary prevention of fractures, but uncertainties about its effectiveness and cost-effectiveness persist.

Methods

We developed a state-transition probabilistic microsimulation model to quantify the cost-effectiveness of various interventions to prevent fractures in 50-year-old postmenopausal women without osteoporosis. We compared no supplementation, vitamin D₃ (800?IU/day) with calcium (1,200?mg/day), and vitamin K₂ (45?mg/day) with vitamin D₃ and calcium (at the same doses). An additional analysis explored replacing vitamin K₂ with vitamin K₁ (5?mg/day).

Results

Adding vitamin K₂ to vitamin D₃ with calcium reduced the lifetime probability of at least one fracture by 25%, increased discounted survival by 0.7 quality-adjusted life-years (QALYs) (95% credible interval (CrI) 0.2; 1.3) and discounted costs by $8,956, yielding an incremental cost-effectiveness ratio (ICER) of $12,268/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 95% and the population expected value of perfect information (EVPI) was $28.9 billion. Adding vitamin K₁ to vitamin D and calcium reduced the lifetime probability of at least one fracture by 20%, increased discounted survival by 0.4 QALYs (95% CrI ?1.9; 1.4) and discounted costs by $4,014, yielding an ICER of $9,557/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 80% while the EVPI was $414.9 billion. The efficacy of vitamin K was the most important parameter in sensitivity analyses.

Conclusions

Lifetime supplementation with vitamin K, vitamin D₃, and calcium is likely to reduce fractures and increase survival in postmenopausal women. Given high uncertainty around the cost-effectiveness estimates, further research on the efficacy of vitamin K on fractures is warranted.     

Endoscopic nephrectomy in children: is retro the way forward?

OBJECTIVE: To determine the benefits of nephrectomy in children performed via a retroperitoneoscopic approach compared to the laparoscopic route. MATERIALS AND METHODS: We reviewed all endoscopic nephrectomies performed at our institution from August 1998 to February 2003. RESULTS: A total of 32 endoscopic nephrectomies were undertaken: 22 laparoscopic nephrectomies with 5 conversions to open surgery, and 10 retroperitoneoscopic. The main indication for surgery was poor function secondary to either reflux or obstructive nephropathy. Intraoperative heart rate changes were less marked in patients undergoing retroperitoneoscopic nephrectomy. The median operative time for retroperitoneoscopic nephrectomy was 65 minutes and 95 minutes for laparoscopy. Epidural analgesia was not required in successful endoscopic nephrectomies. The median postoperative morphine requirement in the retroperitoneoscopic group was 110mcg/kg compared to 280mcg/kg in the laparoscopic group. The majority of patients who had successful endoscopic nephrectomies were discharged to home within 2 days of surgery. CONCLUSION: Retroperitoneoscopic nephrectomy appears to be a safe technique in children, with reduced intraoperative physiological effects compared to the laparoscopic approach. Operative time was generally shorter than the laparoscopic approach and there appeared to be an additional benefit of reduced postoperative pain.