Surgical Myocardial Revascularization versus Percutaneous Coronary Intervention with Drug-Eluting Stents in Octogenarian Patients

Objective: Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization.Methods: We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006.Results: Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis.Conclusion: Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.     

Breast Conservation After Neoadjuvant Chemotherapy

Background Tumor downstaging by preoperative neoadjuvant chemotherapy in patients with locally advanced breast tumors allows breast conservation in women who were previously candidates for mastectomy. Nevertheless, lumpectomy success in such cases cannot be fully achieved. The aim of this study was to create a quantitative tool for preoperative evaluation of the success of breast conservation in such patients.Methods The study population included 100 consecutive patients with stage II and III breast cancer who were designated for lumpectomy and 19 patients who were designated for mastectomy. All patients received neoadjuvant therapy. Breast-conserving surgery was offered in accordance with clinical and esthetic criteria. Demographic details and clinical, imaging, and pathologic information were collected from medical files. A decision protocol for classifying patients to lumpectomy or mastectomy was built by using the Classification and Regression Trees procedure based on preoperative characteristics.Results Three factors were found to be the main predictors for successful breast conservation: absence of diffuse microcalcifications as seen in the pretreatment mammogram, a postchemotherapy tumor size of < 25 mm, and the existence of a circumscribed lesion on mammography.Conclusions The use of these criteria as a basis for decision on the type of surgery may decrease the performance of unnecessary procedures.     

Laparoscopic colectomy is associated with decreased postoperative gastrointestinal dysfunction

Background  Major abdominal surgery is associated with early postoperative gastrointestinal dysfunction, which may lead to abdominal distention and vomiting, requiring nasogastric (NGT) tube insertion. This study aimed to compare the rates of early postoperative NGT insertion after open and laparoscopic colorectal surgery. Methods  A retrospective chart review was performed for patients who underwent colorectal surgery with removal of the NGT at completion of surgery. Patients who required reinsertion of the NGT in the early postoperative course were identified. The reinsertion rate for patients who underwent laparoscopic surgery was compared with that for the open group. Results  There were 103 patients in the open group and 227 in the laparoscopic group. In the laparoscopic group, 42 patients underwent conversion to open surgery. Reinsertion of the NGT was required for 18.4% of the patients in the open group, compared with 8.6% of the patients for whom the procedure was completed laparoscopically (p = 0.02). Conversion to open surgery resulted in a reinsertion rate of 17%. Conclusion  Laparoscopic colorectal surgery is associated with decreased postoperative gastrointestinal dysfunction, resulting in a significantly lower NGT reinsertion rate. Presented as a poster at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, (SAGES), Dallas, Texas, 26–29 April 2006, and at the annual meeting of the European Society for Endoscopic Surgeons (EAES), Berlin, Germany, 13–16 September 2006.     

Laparoscopic Management of Lap-Band<Superscript>®</Superscript> Slippage

Background. The Lap-Band^? is generally associated with a low morbidity rate. Although gastric slippage through the band remains a concern, the rate has diminished with new band placement techniques. Methods. Between November 2000 and June 2002, 198 Lap-Band? Systems were inserted in patients in the Houston, Texas, area. 4 of these patients, plus an additional patient whose Lap-Band^? had been inserted by another surgeon, developed slippages, and in each case the gastric slip was corrected and the band was salvaged and repositioned laparoscopically. To facilitate dissection and repositioning of the band in 3 of these patients, the band had to be unlocked using a simple laparoscopic technique. Results. All patients were discharged the morning following surgery with no complications and good position of the band as evidenced by esophagogram study and resolution of symptoms. After 2 to 12 months follow-up, all 5 patients remain symptom-free and continue to lose weight. Conclusions. Gastric slippage with the Lap-Band^? can be managed by laparoscopic salvage and repositioning of the slipped band.     

The effect of growth hormone on the development of diabetic kidney disease in rats.

BACKGROUND: Nephropathy is the most severe complication of diabetes mellitus. We investigated the effect of exogenous growth hormone (GH) administration on renal function and matrix deposition in the streptozotocin (STZ) model of type I-diabetic rat. METHODS: Adult female STZ-diabetic rats (D), non-diabetic control rats injected with saline (C) and control and diabetic rats injected with bovine GH for 3 months (CGH and DGH, respectively) were used. RESULTS: The usual renal hypertrophy seen in D animals was more pronounced in the DGH group. Creatinine clearance increased only in the D rats, but not in the other groups, including DGH. Albuminuria was observed in the D animals but was significantly elevated in the DGH group. Glomeruli from DGH animals showed more extensive matrix accumulation (manifested as an increase in mesangial/glomerular area ratio). Renal extractable insulin-like growth factor (IGF-I) mRNA was decreased in the D and DGH groups, but renal IGF-I protein was not significantly increased. Renal IGF binding protein-1 was increased in the D groups and further increased in the DGH group, at both the mRNA and protein levels. CONCLUSIONS: GH-treated diabetic rats had less hyperfiltration and more albuminuria, concomitant with more glomerular matrix deposition, when compared with regular diabetic animals. This was associated with a significant increase in renal IGFBP-1, and dissociated from IGF-I changes. Thus, in this model, GH exacerbates the course of diabetic kidney disease.     

Treatment of severe late-onset Perthes’ disease with soft tissue release and articulated hip distraction: revisited at skeletal maturity

Purpose  Late-onset Perthes’ disease is diagnosed after 9 years of age. Conservative treatment and conventional surgical techniques have limited ability to reduce the pressure in the joint or change the shape of the femoral head. We used a combination of soft tissue release and joint distraction with a hinged mono-lateral external fixator for these patients. Ten of our patients reached skeletal maturity and were evaluated. Methods  Clinical assessment included: Harris hip score, hip range-of-motion (ROM), limb length discrepancy, and the Oxford hip questionnaire for pain and function. Radiographic assessment included: Sharp transverse acetabular inclination, the uncoverage percentage, the epiphyseal index before surgery (modified Eyre–Brook), at frame removal, and, at last follow-up, the epiphyseal quotient (of Sjovall) and the Stulberg classification. Results  Our study included eight boys and two girls (mean age at surgery 12.3 years, range 9.4–15.1, mean age at last follow-up 18.1 years, range 15.2–22.8). The mean follow-up was 5.7 years (range 4.3–7.8). The mean Harris hip score was 86.3/100 (range 48.5–96); one patient had <85 points. The hip ROM was slightly limited in most patients, and seven patients had limb shortening between 1–4 cm. The mean Oxford hip questionnaire score was 17.4/60 (range 12–31). The mean Sharp transverse acetabular inclination of the affected side was 42° (range 36–54) compared to 39° for the unaffected side (P = 0.045). The mean uncoverage percentage was 37% (range 27–47) compared to 20% for the unaffected side (P = 0.017). The mean epiphyseal index was 0.71 (range 0.31–0.92) before surgery, 0.79 (range 0.50–0.93) at frame removal (P = 0.012), and 0.72 (range 0.51–0.89) at last follow-up (P = 0.646). The epiphyseal quotient for the eight unilateral cases was 0.72 (range 0.49–0.91), and the Stulberg classification was type III for three cases and type IV for seven. Conclusion  Patient satisfaction for function and pain following the combined procedure was good. Radiographic parameters did not change significantly. This should be regarded as a salvage procedure.     

Timing of prophylactic antibiotics in abdominal surgery: trial of a pre-operative versus an intra-operative first dose

When prophylactic antibiotics are used in abdominal surgery it is customary to give the first dose before the operation. Whilst intra-operative antibiotics may be effective in elective surgery, there may be an advantage to starting pre-operatively when there is already an infective focus such as appendicitis. Antibiotics started pre-operatively (group P) have been compared with antibiotics started after initial abdominal exploration (group T). Three intravenous doses of 500 mg metronidazole plus 1 g cephazolin were given in a randomized, double-blind study of 700 emergency and elective high-risk abdominal operations. Antibiotic plasma concentrations at the end of the operation were significantly lower in group P but lay well within the therapeutic range. Wound infection rates, which included minor and delayed infections, were similar in both groups (group P, 57 of 342, 16.7 per cent; group T, 55 of 358, 15.4 per cent; 95 per cent confidence intervals for the difference being -4.1 to +6.7 per cent. In appendicitis, wound infection rates were 12.1 and 13.9 per cent for groups P and T respectively. However, non-fatal deep sepsis was more common in group P (nine cases) than in group T (two cases) (chi 2 = 4.9, P less than 0.05). Postoperative infection was twice as common in obese patients whose body mass index (BMI) was greater than or equal to 26 (39 of 132, 30 per cent) than in thin patients whose BMI was less than 24 (41 of 288, 14 per cent; chi 2 = 13.8, P less than 0.001). This study failed to show any advantage to starting antibiotics pre-operatively, even in appendicitis.