Paget-Schroetter syndrome: what is the best management?

Background. The evaluation of 312 extremities in 294 patients with Paget-Schroetter syndrome (effort thrombosis of the axillary-subclavian vein) over 30 years provides the basis for optimal management determination.

Methods and Results. Group I (35 extremities) was initially treated with anticoagulants only. Twenty-one developed recurrent symptoms after returning to work, requiring transaxillary resection of the first rib. Thrombectomy was necessary in eight. Group II (36 extremities) was treated with thrombolytic agents initially, with 20 requiring subsequent rib resection after returning to work. Thrombectomy was necessary only in four. Of the most recent 241 extremities (group III), excellent results accrued using thrombolysis plus prompt first rib resection for those evaluated during the first month after occlusion (199). The results were only fair for those if seen later than 1 month (42).

Conclusions. An early diagnosis (less than 1 month), expeditious thrombolytic therapy, and prompt first rib resection are critical for the best results.     

Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach?

Background

Obesity is a recognized risk factor for gastroesophageal reflux disease (GERD). Traditional antireflux surgery (fundoplication) may not be appropriate in the morbidly obese, especially when other effective alternatives exist (bariatric surgery).

Methods

A 13-item survey was designed to elicit professional opinions regarding the treatment of medically refractory GERD in obese patients. Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were randomly selected and emailed a link to an online survey.

Results

A total of 550 surgeons were contacted via email, and 92 (17 %) completed the survey. Of the respondents, 88 % perform laparoscopic antireflux surgery, 63 % perform bariatric surgery, and 59 % perform both. Overall, 77 % completed a minimally invasive surgery fellowship. In response to the question “Would you perform a laparoscopic fundoplication in a patient with medically refractory GERD and a BMI of ‘X’?” surgeons were less likely to offer fundoplication at a higher body mass index (BMI). The majority of respondents felt that laparoscopic Roux-en-Y gastric bypass was the best option (91 %), followed by laparoscopic sleeve gastrectomy (6 %). Many had a morbidly obese patient with a primary surgical indication of GERD denied a bariatric procedure by their insurance company (57 %), and 35 % of those surgeons chose to do nothing rather than subject the patient to a fundoplication. Respondents uniformly felt that bariatric surgery should be recognized as a standard surgical option for treating GERD in the obese (96 %).

Conclusion

When surgical treatment of GERD is indicated in an obese patient, bariatric surgery is the optimal approach, in the opinion of surgeons responding to our survey. Unfortunately, third-party payers often decline to provide benefits for a bariatric procedure for this indication. Additional data is necessary to confirm our belief that the opinions elicited through this survey are consistent with the standard of care as defined by the medical community.     

Allograft nephrectomy: what is the best surgical technique?

Background

The objective of this study was to evaluate differences in outcomes of allograft nephrectomies performed by extracapsular versus intracapsular techniques.

Methods

From 1993 to 2010, we performed 89 allograft nephrectomies, including 57 by extracapsular techniques and 32 by intracapsular, chosen according to feasibility at the beginning of the surgery. Fisher exact test and logistic regression were used for statistical analysis. Survival estimates after allograft nephrectomy were calculated according to the Kaplan-Meier method.

Results

After a mean graft survival of 49.7 months, the indications for transplant nephrectomy were chronic rejection (39.3%), acute rejection (22.5%), infection/sepsis (19.1%), gross hematuria (6.7%), renal vein thrombosis (6.7%), renal artery thrombosis (3.4%), and graft rupture (2.3%). Mean operative time, blood loss, transfusions, and complications were similar between the extracapsular and intracapsular groups. The only difference in surgical aspects between the 2 groups was the mean hospital stay, which was longer for the extracapsular group (13.8 vs 7.6 days; P = .01), a result that was confirmed by multivariate analysis (odds ratio, 1.05; 95% confidence interval, 1.0-1.1; P = .03).

Conclusions

Our experience showed no significant advantages in favor of the intracapsular technique except for a shorter length of hospital stay than after the extracapsular procedure.     

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.     

Surgical treatment for stress urinary incontinence with urethral hypermobility: what is the best approach?

A comparative study evaluating the results of three surgical procedures for stress urinary incontinence (SUI) with urethral hypermobility. This is a retrospective study of 189 patients, evaluating the outcomes of the percutaneous needle suspension using bone anchors (PNS), abdominal suspension (AS), and pubovaginal sling (PVS). The mean follow-up was 30.5 months. In our results, the patients were divided into three groups: PNS (49), AS (34), and PVS (106). No differences were found preoperatively. Intraoperatively, PNS had the shortest operative time and lowest estimated blood loss, and it is the only outpatient procedure. However, it had the highest complication rate. PNS had the lowest satisfactory rate (16.7%). This was followed by AS (78%), PVS with cadaveric fascia (90%), and PVS with autologous fascia (94%). In conclusion, PNS is a simple outpatient procedure, but the long-term results are disappointing. Both AS and PVS gave good results. PVS was superior to AS in shorter hospitalization, early recovery and overall patient satisfaction.     

Outcome of testicular sperm extraction in nonmosaic Klinefelter syndrome patients: what is the best approach?

Klinefelter syndrome (KS) is the most common chromosomal disorder associated with male hypogonadism and infertility. Parenthood can be achieved in men with KS by intracytoplasmic sperm injection (ICSI) using testicular spermatozoon. The aim of this study was to evaluate surgical sperm retrieval (SSR) rate in patients with KS and to investigate the approach associated with the highest SSR. This is a retrospective study where all medical records of patients with KS who underwent SSR for ICSI, in our centre in the past 14 years, were reviewed. Forty‐three patients were included in this study. Twenty‐three underwent conventional testicular sperm extraction (TESE), while 20 patients underwent microsurgical TESE (Micro‐TESE). The SSR was significantly higher in the Micro‐TESE group when compared with the TESE group (30% versus 0% respectively). In the Micro‐TESE group, hormonal stimulation was given to 16 patients, while no treatment was given to four patients. SSR was only successful in hormonally treated patients (6/16). When the type of hormone stimulation was evaluated, SSR was higher in patients receiving aromatase inhibitors (27.8%). SSR in patients with KS is significantly higher when using hormonal stimulation by aromatase inhibitors followed by microsurgical testicular sperm extraction.     

Adenocarcinoma of the gastric cardia: what is the optimal surgical approach?

BACKGROUND: The incidence of adenocarcinoma of the gastric cardia is rising in Western countries. This study evaluates prognostic factors associated with surgical management of this cancer. STUDY DESIGN: Medical records of consecutive patients with gastric cardial cancer treated by surgical resection from 1991 through 2001 were reviewed. Survival was analyzed using the Kaplan-Meier method. Prognostic factors were evaluated using log-rank test and Cox regression. Mean followup period was 34 months. RESULTS: Eighty-two patients met study inclusion criteria. Median patient age was 65 years (range 86 to 22). Fifty-nine (72%) patients had type II tumors and 23 (28%) patients had type III tumors, according to the Siewert classification for gastroesophageal junction tumors. Twenty-seven (33%) patients underwent total esophagectomy, 24 (29%) patients underwent extended gastrectomy with thoracotomy, and 31 (38%) patients underwent extended gastrectomy without thoracotomy. Overall postoperative 5-year survival rate was 30%. On multivariate analysis, patient age 65 years and older, absence of lymph node metastasis, and R0 resection emerged as factors independently associated with improved postoperative survival. Frequency with which proximal resection margin was infiltrated with cancer was a function of gross margin length and T stage. Proximal gross margin length of at least 6 cm was required to achieve a microscopically negative proximal margin for T3 and T4 cancers. CONCLUSIONS: Achieving R0 resection should be the goal of surgical therapy for the gastric cardial cancer. The surgical approach should be tailored to individual patients to achieve this goal.     

Appendectomy during early pregnancy: what is the preferred surgical approach?

Appendectomy is the most common nongynecologic surgery performed during pregnancy. Although many surgeons offer laparoscopic appendectomy (LA) as an alternative to open appendectomy (OA) during early pregnancy, few studies have compared the effects of LA versus OA on the fetus and the outcome of the pregnancy. Twenty-eight consecutive females undergoing appendectomy for presumed appendicitis in the first two trimesters of pregnancy between January 2000 and December 2002 were identified retrospectively. Demographic information, weeks of pregnancy at operation, and surgical approach (LA or OA) were recorded. Study outcomes included operative and pregnancy-related complications, length of hospitalization, final outcome of pregnancy, and infant birth weight. Seventeen LA and 11 OA were performed. There were no significant differences in surgical or obstetrical complications, length of hospitalization, or birth weight between the two groups. Two cases of postoperative fetal demise were noted in the LA group. Although not statistically significant, the two fetal losses in the laparoscopic group are concerning. The current study did not demonstrate any advantages to the laparoscopic approach. Pending further investigation, the open approach may be preferred for appendectomy in pregnant patients during the first two trimesters of pregnancy.     

Total joint replacement and blood loss: what is the best equation?

With the population aging, total joint replacements which are an effective method to restore patient’s mobility are an increasing necessity. However, such operations are known to entail serious blood loss, which may have dramatic consequences in patients with chronic diseases or when the prosthesis is revised, a situation where the blood loss is even higher. Therefore, formulas to better estimate the blood loss are available. These formulas may also be used for clinical studies to compare blood loss between different joint replacement techniques. The aim of this review is to provide a clear understanding of the formulas and to help physicians to further improve their blood loss estimation. Moreover, surgeons will then be able to choose the most accurate and user-friendly formula for more comparable data between clinical studies.     

Standard open repair versus minilaparotomy approach for abdominal aortic aneurysms: what is the best approach in patients with ischemic heart disease?

AIM: The beneficial effects of minilaparatomy approach in patients undergoing abdominal aortic aneurysm (AAA) repair have been defined. In this respect, the authors compared treatment outcome and procedure-related mortality rates of minilaparotomy technique with those of open standard repair in patients with ischemic heart disease.\METHODS: The authors retrospectively reviewed data on 212 patients who underwent elective AAA repair via a minilaparotomy approach at the Hospital of Istanbul over an 8-year period from February 1995 to January 2003. The clinical study included 46 patients who have only ischemic heart disease as a sole risk factor. This group was matched in a case-control fashion to a group of 57 patients with similar characteristics who were operated via standard median laparotomy. All available clinical, pathologic and postoperative data were reviewed and analyzed for postoperative outcome.\RESULTS: Mean operative times in mini- and standard laparotomy groups were 190+/-26 min and 165+/-15 min, respectively (P=0.32). Aortic clamping times did not differ significantly between two groups (61+/-12 min vs 53+/-10 min, P=0.43). Blood requirement was lower in minilaparotomy group. Five patients (8.7%) in the standard median laparatomy group died, while one death (2%) occurred in the other group (P<0.01). In patients who have undergone traditional repair, 5 patients suffered from myocardial infarction and 4 patients required prolonged mechanical ventilation. No coronary ischemic event was noticed in minilaparotomy patients. The minilaparotomy group had significantly shorter lengths of hospital (6.2+/-1.1 vs 9.3+/-2.8 days, P=0.03) and intensive care unit (ICU) stays (7.8+/-2.3 vs 14.5+/-3.2 hours, P=0.01). Duration of adynamic ileus (1.9+/-0.6 vs 2.8+/-1.1 days, P=0.02), return to normal diet (3.2+/-1.0 vs 4.6+/-1.3 days, P=0.01) and day of ambulation (1.5+/-0.3 vs 3.2+/-0.7 days, P=0.001) were significantly lower in the minilaparotomy group. The standard median laparotomy group was twice as costly as the minilaparotomy group (3 200+/-600 vs 5 900+/-900 US dollars, P=0.001).\CONCLUSION: The minilaparotomy technique has advantages that include less postoperative morbidity and mortality rates, early resumption of intestinal functions, reduced cost, decreased length of stay in the ICU and hospital. There-fore, the authors believe that this approach is still a valid alternative approach in the treatment of patients with AAA having ischemic heart disease as a risk factor.     

Seminal vesicle invasion: what is the best adjuvant treatment after radical prostatectomy?

Study Type – Therapy (individual cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Seminal vesicle invasion in prostate cancer has a poor prognosis. Nowadays, there is no consensus about the best adjuvant treatment after radical prostatectomy when seminal vesicle invasion is observed in the specimen. To our knowledge, this is the first comparative study between different adjuvant treatments after radical prostatectomy when seminal vesicle invasion is observed in the specimen.

OBJECTIVE

? To evaluate the biochemical‐failure free survival according to different adjuvant treatments in patients who underwent radical prostatectomy (RP) with seminal vesicle invasion (SVI).

PATIENTS AND METHODS

? Between 1994 and 2008, 4090 men underwent RP in nine centres. Of these, 310 men had a SVI. ? Exclusion criteria were: detectable postoperative prostate‐specific antigen, lymph node metastases and follow‐up <18 months. ? Therefore, the study group included 199 patients. Of these, 41 received adjuvant radiotherapy (RT) only, 26 received adjuvant androgen deprivation therapy (ADT) only, 50 received adjuvant ADT combined with RT and 82 were monitored. The endpoint for this analysis was biochemical no evidence of disease (bNED). ? Preoperative prostate‐specific antigen level, specimen Gleason score, age, clinical stage, surgical margin status and adjuvant treatment were evaluated in a multivariable analysis with respect to bNED survival.

RESULTS

? After a mean (range) follow‐up of 60.3 (18–185) months, 88 (44.2%) patients had a biochemical relapse. ? The estimated 5‐ and 7‐year bNED survival were 32.6% and 25.9% for the observation group, 44.4% and 28.6% for the RT only group, 48.4% and 32.3% for the ADT only group and 82.8% and 62.1% for the adjuvant ADT combined with RT group. ? On multivariate analysis, only adjuvant ADT combined with RT (P < 0.001) was an independent prognostic factor of biochemical relapse.

CONCLUSIONS

? RP appeared to be insufficient as a single treatment for patients with SVI. ? The findings of the present study suggest that adjuvant ADT combined with RT after RP for patients with SVI confers a substantial benefit on 5‐year bNED survival.     

Open Versus Minimally Invasive Esophagectomy: What is the Best Approach? Minimally Invasive Esophagectomy

Introduction  

Esophageal cancer is a complex disease that is typically discovered at a late stage and is associated with a poor overall survival rate.