Meconium ileus: a review 1972-1990.

This article reviews the management and mortality of 53 neonates with meconium ileus and cystic fibrosis treated in one paediatric surgical centre from 1972 to 1990. Forty-four patients (83 per cent) presented with simple meconium ileus and 26 of 40 patients in this group were successfully treated with Gastrografin enemas. Four patients suffered a perforation as a result of the enema (perforation rate 5 per cent). The 1-year survival rate for simple meconium ileus was 81 per cent and for complicated meconium ileus 75 per cent.     

Acute appendicitis during pregnancy

Forty-one appendectomies were performed on pregnant patients during the period 1973-1983. The preoperative diagnosis of acute appendicitis was correct in 57 per cent of the cases (24 patients). Presenting complaints, physical examinations, and laboratory analysis did not prove helpful in establishing the diagnosis. The incidence of acute appendicitis during pregnancy was 1:4172 (birth/pregnancy). Rapid surgical intervention probably contributed to the low (25%) incidence of perforated appendices. A transverse incision and general anesthesia were preferred. There was no maternal mortality and a 2 per cent rate of fetal loss.     

Components separation technique and laparoscopic approach: a review of two evolving strategies for ventral hernia repair

When faced with large ventral hernias, surgeons frequently must choose between higher incidence of recurrence after primary repair and higher incidence of wound complications after repair with mesh. The aim of this study is to compare early outcomes between laparoscopic repair (LR) and components separation technique (CST), two evolving strategies for the management of large ventral hernias. We reviewed 42 consecutive patients who underwent CST and 45 consecutive patients who underwent LR of ventral hernia defects of at least 12 cm2. Demographics, hernia characteristics, and short-term outcomes were compared between groups. Patients in the LR group were younger (53 +/- 2 vs 68 +/- 2 years, P < 0.0001), had greater body mass index (34 +/- 2 vs 29 +/- 1 kg/m2, P = 0.02), and had larger hernia defects (318 +/- 49 vs 101 +/- 16 cm2, P < 0.0001) than patients in the CST group. The LR resulted in shorter length of hospital stay (4.9 +/- 0.9 vs 9.6 +/- 1.8 days, P < 0.0001), lower incidence of ileus (7% vs 48%, P < 0.0001), and lower incidence of wound complications (2% vs 33%, P < 0.001) than the CST. Both techniques resulted in similar operative times, transfusion requirements, and mortality. Recurrences occurred in 7 per cent of patients at mean follow-up of 16 months in the CST group and 0 per cent at mean follow-up of 9 months after LR. The LR may have a short-term advantage over the CST in terms of incidence of ileus, wound complications, and hospital stay. Because of their unique advantage over traditional hernia repairs, both techniques may play a significant role in the future treatment of large ventral hernias. Adequate training will be essential for the safe and effective implementation of these techniques within the surgical community.     

Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants

BACKGROUND: In regional and population studies, the mortality rate within 30 days of elective surgical repair of abdominal aortic aneurysm is approximately 8 per cent. Identification of preoperative factors associated with this mortality risk is important for informing surgical policy and may suggest suitable preoperative interventions. METHODS: In the UK Small Aneurysm Trial, 820 patients aged 60-80 years underwent elective open surgical repair of an abdominal aortic aneurysm. The relationship between 30-day mortality rate and 13 prespecified potential prognostic factors was investigated. The value of a published clinical prediction rule was also evaluated. RESULTS: The postoperative mortality rate was 5.6 per cent overall (46 deaths in 820 patients). Postoperative mortality risk was significantly associated with older age (P = 0. 03), higher serum creatinine level (P = 0.002) and lower forced expiratory volume in 1 s (FEV1) (P = 0.003) in univariate analyses. Evidence of a relationship between age and postoperative death was weakened (P = 0.08) after adjustment for creatinine level and FEV1. The predicted postoperative mortality risk ranged from 2.7 per cent in younger patients with below average creatinine levels and above average FEV1, to 7.8 per cent in older patients with above average creatinine levels and below average FEV1. The published clinical prediction rule did not validate well on these data; observed risk did not correlate with predicted risk except for a small group of high-risk patients. CONCLUSION: Poor preoperative lung and renal function was strongly associated with postoperative death. Age was less important once these two important prognostic factors had been taken into account. The potential for preoperative improvement in lung and renal function to reduce postoperative mortality rates should be addressed in future studies.     

Clinical characteristics and outcomes of surgical patients with vancomycin-resistant enterococcal infections

The purpose of this study is to determine risk factors associated with mortality in surgical patients with vancomycin-resistant enterococcus (VRE) infections. The hospitalizations of surgical patients with VRE infections from January 1998 to December 2001 were reviewed. Statistical analysis was performed using the Student's t test, chi square, and Fisher's exact test. Thirty-one surgical patients (male:female, 14:17) with a mean age of 51.9 years (range, 21-83 years) developed VRE infection. Infections included bacteremia (12), urinary tract (11), surgical site (seven), and soft tissue (five) infections and intra-abdominal abscess (one). Nine (29.0 per cent) patients received recent outpatient antibiotics and 20 (64.5 per cent) were on steroids. Fifteen (48.4 per cent) patients were treated with intravenous vancomycin before infection. Twelve (38.1 per cent) patients died with a trend toward advanced age (60.7 vs 46.5 years; P = 0.06). The incidence of VRE infection in kidney transplant patients was 1.8 per cent. Six transplant patients (five kidney and one kidney/ pancreas) developed VRE infections with four deaths. Hypertension (P = 0.04), coronary artery disease (P = 0.02), and the need for intra-arterial pressure monitoring (P = 0.04) were associated with mortality. Isolate location, gender, diabetes, renal dysfunction, respiratory disease, liver disease, and serum albumin were not associated with mortality. Kidney transplant patients have a high incidence of VRE infection. Surgical patients with VRE infections have a high mortality rate. Hypertension and coronary artery disease are risk factors for mortality.     

Gallstone ileus: Review of the literature and presentation of thirty-four new cases

An analysis of thirty-four patients with gallstone ileus is integrated with a review of the literature on the subject. Surgical treatment was carried out in thirty-two patients, with an overall operative mortality of 19 per cent. Three patients were treated by one stage enterolithotomy, fistula repair, and cholecystectomy without operative mortality, emphasizing the merit of one stage treatment in selected, well prepared patients. A 6 per cent incidence of carcinoma of the gallbladder was noted in this series of patients.     

Factors affecting prognosis in patients with gastric trauma

Morbidity and mortality after gastric injury is usually the result of associated injuries. The authors conducted a retrospective study of 544 consecutive patients with gastric trauma requiring emergency surgery. Blunt injuries had the highest mortality and length of stay. The mortality of a proximal stomach injury was 43 per cent (9 of 21) and was significantly higher than the 19 per cent mortality seen in patients with more distal injuries (P < 0.01). The majority of gastric injuries were closed primarily (492 of 544 or 90%). The patients requiring more than a primary repair had a higher mortality (22 of 52 or 42% vs. 87 of 492 or 18%; P < 0.001), required more blood (16+/-16 U vs. 6+/-11 U; P < 0.001), had an increased rate of surgical site infections (17 of 52 or 33% vs. 75 of 492 or 15%; P = 0.001), and had an increased length of stay (20+/-30 days vs. 13+/-18 days; P = 0.024). There were 22 patients with an isolated gastric injury, and all of these patients survived. Patients with an associated arterial injury had the highest mortality (49%) and highest incidence of shock (64%). Patients with colon and gastric injuries had the highest (48 of 176 or 52%) surgical site infection rate. Isolated gastric injury is rare, but is associated with low morbidity and mortality. The mechanism of injury, location of injury, and type of repair used all affect patient outcomes with gastric injury.     

Upper gastrointestinal bleeding following renal transplantation

Upper gastrointestinal bleeding has been shown to be a common complication of renal transplantation and one which carries a significant risk of mortality. In a retrospective review of 200 consecutive renal transplants in 194 patients, we found an incidence of only 6 per cent and a mortality rate of 8.3 per cent. Allograft survival in this group of patients was 58 per cent. These results are the product of careful preoperative evaluation, close attention to the patients for early signs of bleeding, and aggressive diagnostic and therapeutic intervention at the first evidence of bleeding. We also report an association of hypercalcemia with post-transplant upper gastrointestinal bleeding, with cessation of bleeding after parathyroidectomy.     

What Is the 30-Day Mortality Burden After Elective Total Hip Arthroplasty? An Analysis of 194,062 Patients

BackgroundThis study aims to answer the following questions regarding elective total hip arthroplasty (THA): What is (1) the overall 30-day mortality rate; (2) the mortality rate when stratified by age, comorbidities, and preoperative diagnosis; and (3) the distribution of patient demographics, comorbidities, and preoperative diagnoses between the mortality and mortality-free cohorts?MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all patients undergoing elective primary THA (2011-2018). A total of 194,062 patients were categorized based on the incidence of 30-day mortality (mortality: n = 206 vs mortality-free: n = 193,856). Patient demographics, comorbidities, and preoperative diagnosis (osteoarthritis [OA] vs non-OA) were recorded. Age category, American Society of Anesthesiologists (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis.ResultsThe 30-day mortality rate was 0.11%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.049% (40-49 years), 0.052%(50-59 years), 0.071% (60-69 years), 0.133% (70-79 years), and 0.352% (80-89 years). The percentage of deaths per ASA score was 0% (ASA I), 0.035% (ASA II), 0.174% (ASA III), and 1.008% (ASA IV). The percentage of deaths per CCI score was 0.09% (CCI = 0), 0.23% (CCI = 1), 0.74% (CCI = 2), 3.21% (CCI = 3), 4.76% (CCI = 4), and 0.57% (CCI ≥ 5). Non-OA diagnoses were significantly more frequent in the mortality cohort (16.0% vs 7.6%; P < .001).ConclusionThe risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. The overall rate of death was higher in the non-OA cohort compared to the OA cohort.Level of EvidenceIII.     

Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: a 14-year experience

OBJECTIVE: There is a paucity of data regarding gastrointestinal (GI) complications after descending thoracic and thoracoabdominal aortic (DTA/TAA) surgical repairs. We examined our 14-year experience with these repairs to determine the incidence, outcomes, and risk factors for postoperative GI complications. METHODS: Between February 1991 and February 2005, we repaired 1,159 DTA/TAA. Data were prospectively collected. The mean patient age was 68 years and 36% were women. Complications were classified as biliary disease, hepatic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, and ileus. Risk factors for the occurrence of GI complications were ascertained by univariate and multivariable analysis. RESULTS: Of the 1,159 patients, 81 had 109 GI complications, for a 7% incidence. The mortality associated with GI complications was 39.5% compared with 13.5% (P < .0001) in patients without GI complications. The incidences of complications were bowel ischemia, 2.5% with 62% mortality; biliary disease, 0.3% with 75% mortality; hepatic dysfunction, 1.6% with 38% mortality; acute pancreatitis, 0.3% with 20% mortality; GI bleeding, 1.5% with 29% mortality; peptic ulcer disease, 0.9% with 30% mortality; and ileus, 2.2% with 26% mortality. Postoperative biliary disease (odds ratio [OR], 16.58; P = .001), hepatic dysfunction (OR, 3.58; P = .006), and bowel ischemia (OR, 10.03; P = .0001) were significantly associated with an increased postoperative mortality. Risk factors for the occurrence of GI complications were visceral involvement of the aortic repair (TAA extent II, III, and IV) (OR, 2.08; P = .002) and low preoperative glomerular filtration rate (OR, .98; P = .0002). CONCLUSION: Biliary disease, hepatic dysfunction, and bowel ischemia after DTA/TAA surgical repairs were associated with an increased mortality. Visceral involvement and preoperative renal insufficiency were risk factors for the occurrence of GI complications.     

Early surgical intervention for fulminant pseudomembranous colitis

The objective of this study of a retrospective case series was to determine factors associated with survival after surgical intervention in pseudomembranous colitis (PMC). The study was conducted at a tertiary care medical center and comprised 36 patients who underwent colectomy for fulminant PMC from 1995 to 2006. Patients including 21 females ranged from 40 to 89 years of age (mean, 70 years). Comorbidities included diabetes (39%), cardiovascular disease (77%), chronic obstructive pulmonary disease (47%), and intake of immunosuppressive medications (45%). Seventy-two per cent received antibiotics in the previous 2 months. Only patients with a confirmation of PMC on pathology specimens were included in the study. All patients underwent colectomy. Patients were stratified into two groups: survivors and nonsurvivors. Various clinical factors/ parameters used in the management of patients with PMC were studied in these two groups. Survival was correlated with mean white blood cell count (23,000 survivors versus 40,000 nonsurvivors, P < 0.01); multisystem organ failure (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05); and preoperative pressors (16 per cent survivors versus 47 per cent nonsurvivors, P < 0.05). Overall mortality for the study period was 47 per cent. Mortality rate analysis revealed a lower rate for the more recent years (32 per cent for 2000 to 2006 versus 65 per cent for 1995 to 1999, P < 0.05). In the more recent years, the time elapsing before colectomy was also lower (1.4 days versus 2.5 days, nonsignificant), and patients had less preoperative hemodynamic instability (70 per cent versus 31 per cent, P < 0.03). In one institution, survival after surgery for PMC was found to be associated with a mean white blood cell count (< 37,000), nondependence on preoperative vasopressors, and surgical intervention before the onset of hemodynamic instability.     

Adverse surgical outcomes among patients with cognitive impairments.

To determine the factors that contributed to adverse outcomes, the records of 59 cognitively impaired patients with nonfatal complications (n = 23) or death (n = 36) on a general surgery teaching service over a 30-month period were examined retrospectively. Specific complications are reported. Patient, disease, and management factors related to mortality and morbidity are identified. Patients with cognitive impairments had a higher mortality rate (9.6 vs 6.3%) and approximately the same rate of nonfatal complications (6.1 vs 7.6%) when compared with general surgery patients as a whole. Patient characteristics including age over 70, dementia, nursing home residence, contractures, inability to communicate, need for total care, and gross malnutrition were associated with fatal outcomes. Vascular, colonic, esophageal, gastric, or duodenal conditions, emergency admission, urgent operation, and admission APACHE II scores greater than or equal to 15 were disease-related factors associated with mortality. Management risk factors were prehospital or inpatient diagnostic delays and technical or judgmental errors of surgical management. Twenty-four of 36 deaths were directly related either to a diagnostic delay (11), an operative technical error (11), or a judgmental error of postoperative airway management (2). Eighty-five per cent of diagnostic delays (11/13) and 37 per cent (11/30) of technical errors resulted in mortality. Suggestions for improving the care of these patients are discussed.     

Mortality and morbidity in pretransplant bilateral nephrectomy: analysis of 305 cases.

The surgical riks were analyzed in 305 patients with end stage renal failure who underwent bilateral nephrectomy through midabdominal approach in preparation for kidney transplantation. The over-all mortality rate was 3.6 per cent. Age was the most significant risk factor in the mortality. Patients less than fifty years of age had an operative mortality rate of 3.1 per cent while those more than fifty years had an operative mortality of 11.1 per cent. Other pertinent risk factors were preoperative complications of renal failure and additional surgical procedures at the time of bilateral nephrectomy. The leading causes of death were those of cardiovascular complications and infection. The morbidity rate was 58.7 per cent being major in 18 per cent and minor in 40.7 per cent. Bilateral nephrectomy is recommended selectively in patients with (1) chronic pyelonephritis with urinary tract infection, (2) major vesicoureteral reflux, (3) immunologically active glomerulonephritis, (4) severe hypertension uncontrollable by adequate dialysis, and (5) extremely large or infected polycystic kidneys.     

Recurrence of colorectal cancer after sutured and stapled large bowel anastomoses.

The purpose of this study was to compare surgical stapling and manual suturing techniques with respect to the incidence of tumour recurrence in patients with colorectal cancer: 294 patients undergoing potentially curative resections for colorectal cancer were randomly allocated to receive sutured (n = 142) or stapled (n = 152) anastomoses. The mean (s.e.m.) incidence of tumour recurrence at the end of 24 months was 29.4(4.4) per cent in the sutured group, compared with 19.1(3.9) per cent in the stapled group (P less than 0.05). The corresponding rates for cancer-specific mortality at 24 months were 22.3(4.1) per cent and 10.9(3.0) per cent respectively (P less than 0.01). A multiple regression analysis revealed that the influence of anastomotic technique on recurrence and mortality rate was independent of tumour stage. These results suggest that in colorectal cancer surgery the use of stapling instruments for anastomotic construction could be associated with a reduction in the incidence of recurrence and mortality rate by as much as 50 per cent.     

Intra-abdominal sepsis following pancreatic resection: incidence, risk factors, diagnosis, microbiology, management, and outcome

Intra-abdominal sepsis (IAS) following pancreatectomy is associated with the need for therapeutic intervention and may result in mortality. We retrospectively reviewed patients developing IAS following elective pancreatectomy. Risk factors for the development of sepsis were assessed. The microbiology of these infections was ascertained. The number and type of therapeutic interventions required and infectious-related mortality were recorded. One hundred ninety-six patients had a pancreatectomy performed, 32 (16.3%) of who developed IAS. Infected abdominal collections were diagnosed and therapeutically managed at a mean of 11.8 days after the index procedure (range, 4-33). Eleven of 32 (34%) of these infections were diagnosed on or before postoperative day 6, 10 of who had Whipple procedures. Statistically significant risk factors included an overt pancreatic fistula (18.8% vs 5.5%) and a soft pancreatic remnant (74.2% vs 42.3%), but not the lack of intra-abdominal drainage, an antecedent immunocompromised state, postoperative hemorrhage, or the preoperative placement of a biliary stent. Fifty-five per cent had polymicrobial infections and 26 per cent of isolates were resistant organisms. Nineteen per cent and 48 per cent of patients had an isolate positive for fungus and a Gram-positive organism, respectively. Forty-seven therapeutic interventions were used, including 10 reoperations. Length of stay was significantly prolonged in those with IAS (28.5 vs 15.2 days) and mortality was higher (15.6% vs 1.8%). We conclude: 1) septic morbidity after pancreatectomy is associated with a soft pancreatic remnant and an overt pancreatic fistula and in this series resulted in a prolonged length of stay and a significant increase in procedure-related mortality; 2) infected fluid collections may occur very early in the postoperative period before frank abscess formation, and an early threshold for diagnostic imaging and/or therapeutic intervention should be entertained in those with clinical deterioration; and 3) these infections are often polymicrobial and frequently include resistant and nonenteric organisms.     

Systematic review and meta‐analysis of outcomes following emergency surgery for Clostridium difficile colitis

Background:

Only a small proportion of patients with severe Clostridium difficile infection (CDI) undergo emergency surgery, the timing and nature of which is unclear. The aim of this study was to describe the operations performed and to identify factors predictive of death following emergency surgery for CDI.

Methods:

A systematic review of published literature was performed for studies comparing survivors and non‐survivors of emergency surgery for CDI. Meta‐analysis was carried out for 30‐day and in‐hospital mortality.

Results:

Overall 31 studies were included, which presented data on a total of 1433 patients undergoing emergency surgery for CDI. Some 1·1 per cent of all patients with CDI and 29·9 per cent with severe CDI underwent emergency surgery, although rates varied between studies (0·2–7·6 and 2·2–86 per cent respectively). The most commonly performed operation was total colectomy with end ileostomy (89·0 per cent, 1247 of 1401 detailed surgical procedures). When total colectomy with end ileostomy was not performed, reoperation to resect further bowel was needed in 15·9 per cent (20 of 126). Where described, the 30‐day mortality rate was 41·3 per cent (160 of 387). Meta‐analysis of high‐quality studies revealed that the strongest predictors of postoperative death were those relating to preoperative physiological status: preoperative intubation, acute renal failure, multiple organ failure and shock requiring vasopressors.

Conclusion:

This systematic review supports total colectomy with end ileostomy as the primary surgical treatment for patients with severe CDI; other surgical procedures are associated with high rates of reoperation and mortality. Less extensive surgery may have a role in selected patients with earlier‐stage disease. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

The extent of cryosurgery increases the complication rate after hepatic cryoablation

Although there have been many reports on the use of cryosurgery to ablate hepatic malignancies none have specifically examined the relationship of complication rates to the extent of cryoablation. A retrospective review from January 1997 to May 2002 identified 98 patients treated with hepatic cryotherapy. The extent of the cryosurgery was determined by the total number of lesions (TNL) and total estimated area (TEA) of the lesions from preoperative evaluation by CT scan and intraoperative evaluation by ultrasound. The major complication rate was 11 per cent. The 30-day mortality was 0 per cent, but the late procedure-related mortality was 2 per cent. Increasing the extent of cryotherapy measured by intraoperative ultrasound demonstrated significant increases in the complication rate and length of stay (LOS). With cryoablation of TEA > or = 30 cm2 there was a significant increase in the overall complication rate (56% vs 23%; P = 0.003) and LOS (8.8 +/- 6.9 vs 6.1 +/- 4.2; P = 0.022) compared with TEA < 30 cm2. Performance of concurrent procedures also led to a significant increase in complications (69% vs 29%; P = 0.010) and LOS (8.6 +/- 6.8 vs 6.0 +/- 4.0; P = 0.019). Multivariate analysis, however, showed intraoperative TEA > or = 30 cm2 to be the most significant independent predictor of increased complications and prolonged LOS.     

Abdominal aortic aneurysmorrhaphy and cholelithiasis in the era of endovascular surgery

The incidence of acute cholecystitis complicating standard abdominal aortic aneurysm (AAA) repair has been reported between 0.3 and 18 per cent. This has prompted considerable debate regarding the management of cholelithiasis discovered incidentally during open aortic reconstruction. This study seeks to determine the incidence of cholelithiasis and acute cholecystitis after endovascular AAA repair and evaluate options for management. Between February 1996 and October 2001 492 patients underwent endovascular AAA repair. All the procedures were performed in the operating room under fluoroscopic guidance. Epidural (98.9%), local (0.5%), or general (1.7%) anesthesia was used during these cases. The incidence of cholelithiasis and acute cholecystitis was evaluated by CT scan and abdominal ultrasound. Serum measurements of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total and direct bilirubin, and amylase were performed and clinical assessment was conducted at 1, 6, and 12 months postoperatively and annually thereafter. The mean age of these patients was 76.6 years; 84% were male. Comorbid medical conditions were present in all patients (average 3.5 conditions/patient). Follow-up ranged from 2 to 35 months (mean 12.8 months). Endovascular stent graft deployment was successful in 486 of the 492 patients (98.8%). Six patients were converted to standard open repair because of inability to achieve successful endovascular aneurysm repair. The perioperative major morbidity rate was 14.9 per cent. Minor morbidity rate was 8.5 per cent. The perioperative mortality rate was 1.9 per cent. No deaths were related to biliary disease. Cholelithiasis was identified in 64 (13%) patients preoperatively. One of 64 patients with a prior Billroth II reconstruction for peptic ulcer disease developed jaundice 8 days after AAA repair as a result of choledocholithiasis that required surgical repair. One patient without gallstones developed acute acalculous cholecystitis on postoperative day 16 as determined on pathologic analysis of the gallbladder. A third patient who had gallstones identified on preoperative CT scan developed calculous cholecystitis 16 months after endovascular AAA repair. These two patients underwent uncomplicated laparoscopic cholecystectomy and recovered uneventfully. The incidence of postoperative symptomatic cholelithiasis is 1.6 per cent (one of 64). The incidence of postoperative acute cholecystitis was 0.2 per cent (one of 486) and was unrelated to the presence of gallstones. The incidence of delayed symptomatic cholelithiasis was 1.6 per cent (one of 64). Endovascular repair of AAA does not appear to predispose the patient to the development of symptomatic cholelithiasis during the perioperative period. Therefore a preoperative or intraoperative diagnosis of cholelithiasis does not necessitate cholecystectomy in the setting of planned endovascular AAA repair. Patients who develop cholecystitis after endovascular AAA repair may be effectively treated by standard laparoscopic techniques.     

The false negative technetium-99m-sestamibi scan in patients with primary hyperparathyroidism: correlation with clinical factors and operative findings

False negative (FN) results limit the efficacy of technetium-99m-sestamibi scanning for parathyroid localization. We determined the incidence of FN results and attempted to correlate it with clinical and operative findings. One hundred forty-six patients underwent parathyroidectomy; 89 had primary hyperparathyroidism (76 single adenoma and 13 multiglandular disease) and underwent sestamibi scanning. The false negative rate was 22 per cent with an overall sensitivity of 77 per cent and a positive predictive value of 99 per cent. Patients with single adenomas were more likely to have a true positive scan than those with multiglandular disease [83% vs 38%; odds ratio (OR) = 7.754, 95% confidence interval (CI) = 2.184-27.524; P < or = 0.0001]. Inferior adenomas (90% vs 59%; OR = 6.261, 95% CI = 2.037-19.243; P < or = 0.0001) and larger adenomas (1422.3 +/- 1576.2 vs 474.6 +/- 193.2 g; P < or = 0.0001) were more likely to be detected by sestamibi imaging. Patients with normal preoperative calcium levels were more likely to have an FN sestamibi scan. Sestamibi parathyroid imaging is limited by a 22 per cent FN rate and is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multiglandular disease, superior adenomas, or preoperative normocalcemia.     

Effect of screening mammography on the surgery of breast cancer in Finland: a population-based analysis during the years 1985-2004

A nationwide mammographic screening of women aged 50 to 59 years commenced in Finland in January 1987. We studied the effect of screening on surgical diagnosis, treatment, and survival of breast cancer in one geographic area in Finland. We reviewed the medical records, survival data from Finnish Cancer Registry, and screening data from the Finnish Mammogrphic Working Group of 1049 women who underwent surgery for breast cancer in our hospital between the years 1985 and 2004. Altogether, 35 parameters including diagnostic procedures, operative data, and staging were recorded. The results of tumors detected by mammographic screening (n=156) and interval cancers (n=148) were compared with the tumors detected outside of screening (n=745). The incidence of breast cancer increased from 35 to 72 cases per 100,000 inhabitants, and the percentage of nonpalpable cancers increased from 12 to 33. Approximately 30 women per 100,000 inhabitants were annually referred from mass screening for surgical biopsies, in 60 per cent of which cancer was detected. Breast lump was still a first sign of cancer in 60 per cent of patients. The mammographic screening detected 20 per cent of new breast cancers. The cancers detected by screening were smaller, found at an earlier stage, and their 10-year-survival was better (90% vs 70%) than those detected by other means (P = 0.003). Overall mortality of interval cancers was worse (27%) than screening cancers (6%, P < 0.0001). Mammographic screening detects up to 20 per cent of new breast cancers in a well-defined population area. The prognosis of screening cancers is better than the cancers found outside of screening.